Oncology & Hematology Coding Alert

Here’s what you need to know about vials and units.

Do you find yourself scratching your head when it comes to clotting factor codes? If you are, you’re not alone. Experts say you should look at what clotting factor your physician used and follow a stepwise approach to calculate billable units.

First, Get to Know Clotting Factors

You’ll find a slew of products that may be prescribed for replacement of clotting factors. These medications are produced by varying mechanisms and identified by their unique properties. When coding for clotting factors, validate the specific product your physician prescribed and whether a specific code has been assigned for the product.

Your physician may also prescribe clotting factors to replace a deficiency in the blood. According to the American Federation of Hemophilia, “Hemophilia is treated by replacing the protein that is missing in the blood.” The federation also describes the plasma and recombinant products used to control bleeding in hemophilia. According to the federation, plasma derived products are ‘factor concentrates that are made from human blood’ whereas the recombinant factor concentrates ‘are manufactured using hamster cells.’

Medicare Part B: Medicare covers clotting factors under part B (not under part D). “Per the CMS website in the Outreach and Education section, “if a person with Medicare Part B has been diagnosed with hemophilia, Medicare helps pay for clotting factors they give themselves by injection under this special benefit category,” says Leah Fuller, CPC, Consultant, Pinnacle Enterprise Risk Consulting Services, LLC, CO. “For more information regarding Medicare Drug Coverage under Medicare Part A, Part B, Part C and Part D, visit: https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/downloads/11315-P.pdf.”

Myth #1: Using Clotting Factors Require Medical Supervision.

Reality: Eligible patients should be able to use clotting factors to control bleeding and should be able to do so without any medical supervision. When billing for self-administration, indicate ‘monthly billing’ and write comments to explain the administration.

The bleeding disorders covered by Medicare include Factor VIII deficiency, Factor IX deficiency, and von Willebrand’s disease.

Myth #2: Reporting Clotting Factors Doesn’t Require Vials and Units

Reality: You need to know the type of vial as well as the number of units used and discarded.

When you report clotting factors, follow three simple steps before submitting the claim. This approach applies to physicians and Ambulatory Surgical Centers for the number of HCPCS units billed.

Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina lists the following three steps for clotting factor coding:

1. Check the type of vial in which the product is supplied. If the product / supply is a single dose vial (SDV), the practice should identify the most cost-effective combination of vial sizes to accommodate the ordered dose. Because it is a Single Dose Vial (“SDV”), the entire vial will be billed.
2. Verify the number of units your physician ordered and / or administered to the patient AND identify the number of units of the HCPCS code applicable to the dose(s) given. Bill the amount given on one line of the claim.
3. Determine how many units were supplied in total, how many units will be discarded, report a second line on the claim with the total number of units documented as the wasted amount of the medication and add modifier ‘JW’ to represent the SDV discarded amount.

Myth #3: You Don’t Need to Know the Source of Factor VIII

Reality: You need to know the source of factor VIII to know which code to report.

When your physician administers human derived factor VIII, submit code J7190 (Factor VIII [antihemophilic factor, human] per IU). For porcine derived factor VIII, submit code J7191 (Factor VIII [antihemophilic factor (porcine)], per IU).

One unit for each IU: For each of the codes, J7190 and J7191, you submit one unit for each IU of factor VIII your physician administers.

Look for acquired vs. congenital hemophilia A: Before you select a code for recombinant factor VIII products, confirm whether the patient received treatment for acquired or congenital hemophilia A.

Limit J7188 to acquired hemophilia A: The code descriptor for J7188 specifies the code applies to ‘OBIZUR.’

What is OBIZUR? OBIZUR is a recombinant DNA derived antihemophilic factor. According to the manufacture’s website and FDA package insert, your physician will administer OBIZUR for the treatment of bleeding episodes in adults with acquired hemophilia A.

For every international unit (IU) of OBIZUR, submit one unit of code J7188 (Injection, factor VIII [antihemophilic factor, recombinant], [OBIZUR], per i.u.).

Other recombinant factor VIII: There are other recombinant factor VIII concentrates your physician may administer to children and adults with congenital hemophilia A. The key to finding the right code is determining the exact product prescribed. “Having codes for clotting factors by brand allows coders to capture the most detail by coding for the specific brand the provider prescribed,” Fuller says. For example, if you read your physician used recombinant factor VIII called ‘NovoEight,’ you submit code J7182 (Injection, factor VIII, [antihemophilic factor, recombinant], [NovoEight], per IU).

Your physician may prescribe ‘Xyntha,’ the plasma/albumin free recombinant factor VIII without additives from human or animal material. In this case, you submit code J7185 (Injection, factor VIII [antihemophilic factor, recombinant] [XYNTHA], per IU).

Myth #4: You Don’t Need to Know the Exact Factor VIII Brand

Reality: Carefully read the physician’s documentation for the exact brand of the factor VIII prescribed. In the clinical note, the physician will mention factor VIII administered to the patient. You should look for terms like ‘advate,’ ‘recombinate,’ or ‘kogenate.’ You may not find a dedicated code for one or more of the recombinant factor VIII options. If it is determined the product used does not have a specific HCPCS code, you should submit code J7192 (Factor VIII [antihemophilic factor, recombinant] per IU, not otherwise specified).

How is J7192 different from J7188? Both J7192 and J7188 are for recombinant factor VIII. However, note J7192 is exclusively for OBIZUR. According to the package insert information, this factor VIII product is approved only for use in acquired hemophilia A in adults. The code J7188 is for factor VIII products used in children and adults. J7188 applies when the factor VIII products, for example, ‘Advate’ are used in congenital hemophilia A.

The prescribing information for “Advate” clearly states, “ADVATE [Antihemophilic Factor (Recombinant)] is a recombinant antihemophilic factor indicated for use in children and adults with hemophilia A (congenital factor VIII deficiency).” The full prescribing information is available at: http://www.shirecontent.com/PI/PDFs/ADVATE_USA_ENG.pdf.