Mastering Compliance in Drug Coding and Billing

Lori Cox: Hi, everybody, and welcome back to our latest episode of the pulse where we talk about all things fun and exciting in the coding and billing and revenue cycle worlds. Anything to do with healthcare finance. You're going to find here in our podcast


Lori Cox: today. I have my good friend Stephanie Thebarge with me. Stephanie and I've known each other for several years now. Right? We served on the National Advisory Board together. Thank you for joining us.

Stephanie: Thank you for having me.


Lori Cox: Tell us a little bit about yourself, for those of you who don't know you, which have can't be very many people these days, because you are the Member Relations officer for the NAB. Right? So they should still know who you are.


Stephanie: Yes, I yes, I've been serving almost for 6 years now it's it's crazy. It's that we're in our last year. But I work in New England. So I'm up here in Maine and New Hampshire. I work for a large hematology oncology practice. I'm also a consultant on the side. But I love everything there is to do about oncology and all about the billing, the drugs, and I am the compliance manager up here, so I have to make sure that they are doing it correctly
is a big piece right?


Lori Cox: Yes, it is, and I know you are the Guru when it comes to that stuff, cause I have questions I like to bounce off of you from time to time, like, How are you guys handling this situation, or something odd, cause we all know that weird stuff comes up all the time in all areas. But I feel like hematology and oncology is one area where there could be a thousand different things going on at the same time, and you're trying to manage every little aspect of it right.


Stephanie: Totally totally cause. And with the drugs it's just they're always using using the most up to date, the newest novel therapies. And they're trying, you know, because we're trying to save save lives. That's ultimately our goal.


Lori Cox: Yeah, absolutely. So that's why I brought Stephanie on today. We're gonna talk mainly about drugs and coding and and the waste, especially in the Hemonc world. So Stephanie gave a presentation at Healthcon back in April that I was, I got to listen to cause I was her room person got to monitor her camera and stuff, and it was a great presentation. So I wanted to take that presentation and just kinda talk about some of your key points.


Lori Cox: One of the things that you started off with were and like you just said, we always have new and emerging drugs that are coming out right. So what are the steps that the drug has to go through? 1st of all, they have to get approval from the FDA right.


Stephanie: Correct. Yes, yes, and there they have to. They have to go through that which is. There's there's 4 steps in that approval for the FDA.


Lori Cox: Okay. And how long does that usually take.


Stephanie: So it really depends upon what what we're looking at. As far as the the early steps in any drug approval, there's discovery and development.


Stephanie: And then there's pre clinical research which those typically can take, you know, could be taking several months to 2 years. In that particular timeframe for those those 1st 2 steps, and they're looking at new insights into the disease process to stop and reverse effects of disease. They're looking in in vitro and vivo settings when it gets really interesting, is when it gets to the step 3, which is clinical research, and that


Stephanie: as actually when you're giving it to patients. And and that's when we're giving. You know that you're gonna start with a control group and then they'll have. They're comparing that new treatment to existing treatment. So just the drug itself. Just getting it to that point, you know. So we can start giving it to patients. So they're comparing that new drug. How is it doing, you know, to hundreds of people before they can even get to the piece of the pie, which is the FDA Drug Review. Now, we want to get that drug and that that can take anywhere from. Unfortunately, it can take depending on. If it's fast tracked, it can take 6 to 10 months for a drug to to even be approved after it's already gone through all those steps.


Lori Cox: Oh, wow! So do you guys do those there? Your clinical trials and things like that.


Stephanie: Yes, we do. Clinical trial going, which is another topic, and how to Bill, and and making sure that you have.


Lori Cox: That was where I was going with that I that has to be complicated because these are new drugs. Right? So you don't have that I'm assuming you don't have a hix code right.


Stephanie: Yeah. So sometimes with with these particular drugs, it's not necessarily the new drug, but it's a new reason for why they're giving it. So they might say, like there could be a drug that they believe is going to be really good in colon cancer. But right now it's it's approved for liver cancer. So it sometimes these, the drugs have J. Codes, and they have a pro, you know, and that everything is is already approved for this reason how a lot of these drugs that are already out on the market. They'll get approved for new reasons. Right? So you might start the. They might be approved for 2 reasons, for 2 clinical indications when they're 1st approved of the FDA. And through clinical trials. And all these er you know, areas that we're looking at all of a sudden. Now they're approved for for 5 other things, because they found that that drug, that chemo drug is gonna work on all these other other cancers, which is great, you know it's just, and that's it's exciting. So. But there is my favorite, which is the unclassified drugs, is like nobody likes unclassified.

Lori Cox: Oh!


Stephanie: Or billing, or how to do it, though I know it's it's it's such a it's such a pain. But but you know we do have those that time that you know what is. Some of those drugs are not approved yet, so we can't, bill it, you know. So there's that, it's it's it's definitely the fine line. Yeah.


Lori Cox: I bet. So the once the drug goes through the FDA and then it gets cleared, and then hopefully across our fingers. We get a Hicks picks code sometime in a quarterly update. Right? Is that typically how that goes.


Stephanie: Yup. Yes, so all that information that the FDA has, because the labeler, meaning the manufacturer of that drug, has to send it off to the FDA and say, Here you go. And then that information goes to Cms, and they determine if if what what heck code. So it's basically they basically have to lobby and say, I, I want this hectic code, and then and then Cms approves it. And it's just a matter of some time of waiting for it to be approved.


Lori Cox: I see. Okay? So then, good. So then, once we get the Hix drug, hopefully, we can bill the code to the payers and they are going to recognize that this is a new code, and we don't get.


Stephanie: Yeah.


Lori Cox: Miles.


Stephanie: Really nice. Yes.


Lori Cox: That would be in a perfect world.

Stephanie: Yeah, if you don't have it, it's that time period before it. It does have its own hiccup code. And you're billing A. J. 9, 9, 9, 9 or j, 35, 90. That's when and that's when payers are like you don't know what to do with this, or you gotta give us more information. So it's always they're always every time we send off a claim with a J. 9, 9, 9 9. You're gonna get some sort of. We need more information before we can pay this. So there's only so much we can report in the actual claim detail electronically, to this.


Lori Cox: Right is one of those things that I'm assuming is like the Ndc. Number assuming there is one which there should be if it's been FDA approved right?

Stephanie: Exactly. Yes, every drug has an Ndc. So yes.


Lori Cox: And one of the things I noticed I remember you saying in your healthcom presentation was about, and we I found this as well like the packaging Ndc number, can be different from what's on the actual vial.

Stephanie: Yes, yeah. So when you are in, if you ever go into your pharmacy and like, look at the actual drugs that come in in the package. There's a package which has the Nc. On the outside of it, and then every vial within that package. If there's 5 vials in that package. It's gonna have an Ndc on the inside, and they're usually they're very similar except the last 2 digits. And so you always wanna make sure you're using the package Ndc. Versus the the one that's on the vial. So again you'd know this because most payers they'll kick it back to you and say something's wrong with the Nec. Doesn't match.

Lori Cox: Yeah, right? So we use the one on the package, not the one on the vials themselves. I think that's come up before, and some talks that I've had with other people, and then he mount coding like the Ndc. Number.


Lori Cox: and I'd like the Ndc. Number, because you can use that. I mean, if you have it, you have access to it. You know, you can use that. You could almost type it into Google or codify, or any software. And hopefully it cross walks you to the Xx code. So that's nice. Not always a perfect crosswalk. But sometimes you get to where you want to be, anyway.


Lori Cox: Yes. Okay, great. So the I know one of the biggest changes. I think it came out last year. Right was the Jay Z, and we're not talking about the wrapper, talking about the modifier because what was funny on I have to tell you on your presentation. They do the transcripts, and every time you said JZ. Is in the modifier they put JAY. Dash studio.


Stephanie: That's why I thought that.


Lori Cox: That's pretty hilarious. So, anyway, that.

Stephanie: Like last year is.


Lori Cox: Is that right? That that modifier changed or came out, and they they were manditating or manditating it, I guess, for single dose files right.


Stephanie: Yeah. So it came out. No later than July 1, st 2023, where they came out with it. And they said that basically, by. I started October 1, st 2023 is when they said, Hey, you've got to put this on all your claims. Anything that you have a single dose file where there is no waste.

Stephanie: and that's huge. You know, like, for practices that don't have an automation or don't have a way to automate that kind of information. That was a lot le pretty big lift for providers out there. If they didn't do the if they didn't have that work already built in if they didn't already put the waste in there, and that was when I read the the final rule when they were coming out with this, you know, and I love the comments that people comment on it. So why, why do? Why do you want you read those? And it's like, it's hilarious. Yeah, it really is.


Lori Cox: It is.


Stephanie: Because they're like, you know, like, here's 1 provider. A doesn't want it, because, you know, you're causing more burden to the practice, because now we gotta go and figure, and then, and they were like you should have been doing this for June.

Lori Cox: Anyway.

Stephanie: So. Why, why is it an issue now for Jay Z. You know.


Lori Cox: Right.


Stephanie: And and the reason why they really came out with the Jay Z was because they weren't. People weren't disclosing the waste. And that's and so they're like, Hey, we can get you. Now we have a way to get you, because if you don't put, if you give us a drug that single does file and doesn't not have a Jz. Or Jw. Or any indication that you did anything. Guess what you're not getting it paid. It's denied way to deny.


Lori Cox: Are you seeing other commercial payers wanting the Jay Z, as well.


We did it across the board, because it's hard for 1 1 insurance just to have it. You know, we're gonna do it for this insurance and not for any. So we did it with all insurances. And it is, you know, I haven't actually found a prepayer, because we, because we did it with all payers. We do Jw. For all payers, so we don't. We don't pay or specify. In that case. Because it's just again one more headache that nobody wants to find out. Oh, this this denied because you didn't have a modifier, because this insurance particular wants it so but yeah, so I mean that. So I I don't know if there's if there are certain payers we haven't. We haven't experienced it because we we put it on.


Lori Cox: Good. And I think that that's best practice, too, because you're just saving yourself. Work in the long run right? And.


Stephanie: Nobody will add a Nile.


Lori Cox: Oh, no,


Lori Cox: good. So back to the waste. That is one of the biggest things I think I see, cause you know, I audit practices all across the country, and the waste is never there, and I'm you can obviously tell, because it says that the vial is so many milligrams, and they only gave so many milligrams. So you know, I mean, you hope that they threw it away, and they weren't trying to eliminate.


Stephanie: Legally.


Lori Cox: We use it right? Because we know when that happens, we see the oig constantly coming out with reports of providers who are using drugs incorrectly right, because they're using it single instead of multi instead of single. So yeah, that's always an issue. But I constantly am this allowing charges on audits saying you did not provide waste. And so I just deny the whole line. Item, because that's what a payer would do. Right? They're gonna say, oh, sorry. You know you didn't give us any waste, and there's no Jz. Or Jw. And information. So I you know we can't allow it.


Stephanie: Right? Yeah, definitely, it's they need to make sure that they're documenting that ways. That's that's


Stephanie: that is number one, you know. Ensure that your waste is documented in the medical record, preferably on the Medication Administration Record.


Lori Cox: Right. That's a where I agree. It should be, too, because they're already putting in there how much you know millograms or mls, or whatever is being used. So just document, it should be like a important thing that they have to do. You know, it doesn't let them clear the record or sign the record or anything like that until they get that waste in there, even if it's 0, because they didn't waste any great. At least we know, you know.


Stephanie: Yes, I know I know it's it is nice, actually say it. One of the things that I noticed, too, is, you know it. It can be a limitation with the Emr. Ehr that you have, too, that it doesn't. You know you have your pharmacy in one system, and then your nurses are in the other system. They don't communicate and talk. Guess what that's the that's the problem we've had. I've seen that in consulting with other practices where they don't. They there's they just don't communicate with each other. I'm like.


Lori Cox: Brian.


Stephanie: Do that. You can't have the pharmacy working in a silo, and the nurses working inside. You gotta work together, and you've gotta make sure you put putting that documentation within the medical record because you're gonna get audited.


Lori Cox: That's a really good point about them working in silos. I like that. Yeah. And it shouldn't be that way with any specialty, you know. Not just, but any specialty. We've got to all work together, because at the end of the day even you and I, in our situations where we work. We are here for the patient, you know. That's who we're trying to help. So yeah, we all have to work together. I'd like that silo thing. I'm actually gonna probably have to use that in a presentation or something like that.

Lori Cox: That. And the whole. Yeah, that and the whole Jay z thing, too. We're gonna have to keep that going alright. Well, we're gonna take a really quick break here and we'll be right back with you all.

Lori Cox: Alright, everybody! Welcome back to the pulse we have been chatting about. Well, Jay Z, apparently, and some drugs. In the meantime we're trying to talk about drug coding, but we get a little sidetracked that happens a lot to us that's in it.


Lori Cox: Well, I like.


Stephanie: Do that? Yeah.


Lori Cox: I know it makes it interesting, if nothing else, I guess. Okay. So we were talking about drugs, and we were talking about waste and the modifiers, which is what led us to the Jay Z conversation. What are some websites that you use that could help coders that are struggling to find information about drugs like, I know there's the FDA right.


Stephanie: Right. So the FDA is great. To get just the basic. What was the drug approved for you know, what's the clinical implications? I. Sometimes you can go out there and you can Google it. But the problem with Google is we, you know, as anything. We it's not always reliable, just like Chat gpt. It's not always reliable.


Lori Cox: Yeah, have a.


Stephanie: We, you know we go in there and we try. You know. You could at least get some information. You could glean some information out there. But I'd I like looking, depending on what I'm looking for again. If I'm looking for an Nec. I might go to any see lookup. Which is it's again, you could just go right online and look at. I think it's nec Lookupcom.


Stephanie: You could. If you have a subscription to codifying all other other platforms out there. There's ways you can go in and look up. There might be an add on to your subscription where you can look up the Ndc. The J. Code. All of that information, the what the payment allowances are things like that. So so there's a lot of ones that I that I do look at, but don't discount going to the manufacturer themselves. So if the drug is put out by one manufacturer, you might want to go to that manufacturer's website and look up that particular drug because they always have the package insert on their website because they have to.


Lori Cox: Yeah, absolutely. And some of them go as far as the half coding and billing information.


Stephanie: Yeah, but.


Lori Cox: Take. I mean, I use it. I guess I I research it because I want to make sure that they're telling me correctly right. And I do that with not.


Stephanie: Yeah, like.


Lori Cox: Drugs. I'll do it with like implants or things if I'm looking at, you know, if I need coding information for that. But yeah, the like. Pfizer was one I was on the other day because I had a drug, and I was like, I've this must be a new one, because I've never heard of it. So I was on their website. And they they were like, here's how we think you should, bill it. Course it. It was unclassified because it was brand new, I guess. So. Yeah, that's all. But at least they try to help you out with it, because they know that if


Lori Cox: the doctors aren't getting paid to use their drug, then guess what? They're not gonna want to use their drug right? So.


Stephanie: Exactly. And then, you know, there's there's a national the Nccn, which is definitely something to look at. If you're doing Co coding for oncology specific drugs. So so that's something to to check out. And you know, the Nccn is a national comprehensive cancer network. And they have a drug compendia that you can look up and it gives you links so you can look up the brand name or the you know the generic name, or however, Nate, whatever


Stephanie: you know, maybe you want to look at colon cancer and all the drugs that are used for colon cancer. So it does give you a little bit more insight

Stephanie: specifically into how the drug is being used. So they have a drug companion. It is a I believe it's subscription based as well. But but it is something that's very helpful for prior authorization teams for for people that are, you know, just to make sure that the reasons why you're giving that drug is is being used appropriately by.


Stephanie: and a lot of times a lot of physicians out there are. They have to use their own work. They have their own workflows that they have to go through their own.


Stephanie: I don't know what you call it. It's it's like A,


Stephanie: they might have a website that they have to go through to make sure that they're using a standardized process for, okay, this patient has this kind of cancer I'm going to go follow this kind of pathway is like they like to call it pathways. I don't know if you've heard that before. But clinical pathways.


Lori Cox: Right.


Stephanie: That's what they that's what they in it. So a lot of times. So that

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Stephanie: that prevents providers from, you know, Bill, oh, I'm gonna do this drug. You know, I'm gonna only build this drug. Well, they can't do that. They have to follow the clinical pathway. So it keeps everybody


Stephanie: compliant, which I love.


Lori Cox: Should right. I know.


Stephanie: Exactly.


Lori Cox: Speaking of compliance. So what other? So we've already really talked about waste. We know that that's something that gets commonly missed in the Mr. Are there other issues that you see frequently that you feel like aren't present like orders or signatures, or what other things do you think is a problem.


Stephanie: I think a hard thing is labs, making sure that people are getting those labs that are required prior to them, giving this drug. So let's say, they're an emac, and we need to see their or their iron deficient. And we need to see the iron deficiency lab. The Ferritin levels. Those kind of things are not being drawn within a certain timeframe that are needed for that for that


Stephanie: patient to be in order to get that drug. So that's that's always hard to make sure that the labs are being done appropriately and are they coming back you know, are? Is the hemoglobin. Correct, you know. Like, is the hemoglobin above a 10? Well, you can't give an error mess, you know, if the if it's.


Lori Cox: Right.

Stephanie: Cancer. You know, cancer patient. So there's so looking at those kind of those specific things are important. And you need to have somebody in your team. That's looking at that. Because if you don't have.


Stephanie: if your fin financial advocate, or whoever is looking at that and the patient comes in, and they have a hemoglobin above a 10, let's say for and but they're due to have an errone S, which is something given, for when they're when they're get for iron deficiency. Anemia in, let's say in their cancer like they're they're getting their anemic, maybe they're not inefficient. Sorry. I'm not. They're just regular and emac but in any case they they get it. They if it's over 10 and they can't give, they can't give it. And do they know to not give it? So it's important, like everybody knows on the front end. Because what happens is the billing. We get it. And we're like we can't build this right right.


Lori Cox: Now, if if they got a Abn signed, could you, bill it that way?


Stephanie: Yes, I mean I yes, if you knew it upfront.


Lori Cox: Got one.


Stephanie: Right? What's right?


Lori Cox: Another problem, because they don't always know that they have to get them. And sometimes it's just another paper. They just give it to the patient, patient signs that they don't even know what they're signing sometimes, right? So.


Stephanie: Now.


Lori Cox: Hello!


Stephanie: And that's but and that's it's so hard with those, too, the just getting the workflow. Who's gonna have that conversation with a patient who's gonna make sure that they've checked all those boxes like even when insurance goes back and says, No, we're not gonna pay for this because the patient has this particular lab, and it says, this is particular lab is in this range, and we're not gonna pay for it if it's in this range. But the patient's like, but the patient comes back and saying, I I feel better when I have this drug, and.


Lori Cox: Right and.


Stephanie: It feel makes me feel good, and so.


Lori Cox: Ryan.


Stephanie: Patient wants to say I want to pay out of pocket for it.


Stephanie: Now we've got a whole other thing that we have to deal with. So it's definitely it's a fine line. And making sure everybody's


Stephanie: notified. And you're following all the steps to make sure that you're not


Stephanie: billing it to insurance. If you can't bill it to insurance that you're, you know, patience paying for it. If they're having to pay out of pocket. Those kind of things have to be done. Patient needs to know exactly what they're going to have to pay.


Lori Cox: I agree with you. And that's a good point, too. A good compliance point as well, because I, we know that that's a compliant issue, especially with things like getting the Avians and explaining it like you're supposed to, and and then making sure the drugs get billed and documented correctly. Yeah, it's all kind of a big nightmare sometimes, but it sounds like you have a very good handle on it.

Stephanie: Yeah, we definitely, the teams know definitely we. It is important to make sure you have all the teams involved. Don't don't work in your silo, you know, like you were saying right.


Lori Cox: I know.


Stephanie: Yes, it's important to all work as a team and collaborate and making sure that. Yeah, okay, you've got that, Abn, is that being communicated to the billing office. So they know what to do, how to bill it, what to put on, what modifiers all that stuff has to be. So yeah, definitely


Stephanie: a fun thing that we have to kind of follow through.


Lori Cox: I guess we wouldn't have a job if we didn't have all these fun things to do, though, right? So.


Stephanie: Right. Always have always have new stuff. There's always new stuff happening.


Lori Cox: There is.


Stephanie: Where.


Lori Cox: That's a good thing, especially in Hemong, because we want those new drugs that are constantly going to help patients, you know, and hopefully have a better quality of life.


Lori Cox: So we want that to happen. But it's the back end work that we have to do that makes it a struggle. And so if the physicians don't understand that sometimes, or they just wanna stay in their silo right? And they don't understand that, hey? We need to work together here to figure this out. Get the patient the best care.


Stephanie: Yeah. And it's it's important to that. The physicians do know what's going on like and why they're, you know, they might order a drug. And you're like


Stephanie: that's not going to cover for that particular.


Lori Cox: Right.


Stephanie: And CD. Or an LCD. Out there, or some.


Lori Cox: Yeah, going.


Stephanie: On that. That that drug is not a cover, you know, for this particular indication, or you didn't meet the letter of the the FDA guidelines, meaning that they had to


Stephanie: fail. This drug failed it. How many times have you done that, you know, like, just for a oral oral drug? I swear I have you!


Lori Cox: Right.


Stephanie: Fail this drug before I can take this drug before I go.


Lori Cox: Right, so.


Stephanie: For for my lipids like I like for my hyperlipid like that, you know. For me, personally, I'm like.


Lori Cox: I got a.


Stephanie: Go through all these steps. Okay, before I can even get there. But you can't just go to the magic Drug. You have to go through all the steps 1st and so and have that documented. So it is that communication to them. And like, I know, this drug works really well, and you want to give it to this patient. But you gotta follow these steps and


Stephanie: and and sometimes it can also be. It's hard on the for the patient, too, because the patient they want the magic drug, and they have to go through these. They have to go through the side effects and everything going through to and before they can get there, it's it's it's it's tough, but it's tough. But that's why the FDA has approved it this way, and that's why they've gone through those rigor of all those months of looking at all that research, because they've determined that is the best course of action.


Lori Cox: Hope in the long run. We hope we hope.


Stephanie: We just know the hard, the hard part with cancer patients. There's just not enough time. And that's really the that's the struggle.

Lori Cox: Yes, it is.

Lori Cox: Well, thank you very much. I appreciate your conversation with me today. Thank you for taking time. I know you're you're super busy as we just determined in our in our podcast here.


Stephanie: Yes, yes, it well, you know I love. I love like I said, anytime you talk about drugs. It's exciting. But there's always stuff changing. And that's the other thing you know, and you could. That's why oncology is just you're ever changing, because there's always new drugs out there that come to market. There's always new manufacturers that are baking the drug that are offering a better a opportunity, you know, like perhaps it's, you know, making it more more available, you know, making this one drug more available. I wish they would do that, amongst other things, not just.


Lori Cox: Right.


Stephanie: Drugs. But yeah.


Lori Cox: I think a lot of us feel that way.


Stephanie: Getting. The generics are definitely, you know. It's it's just say there's not a there's a price point to that patient of of allowing the patient not to have to pay so much out of pocket, and it's tough.


Lori Cox: I agree. Yes, it is.

Stephanie: But I appreciate.


Lori Cox: Even call it.


Stephanie: You! There!


Lori Cox: Thank you. Thank you.


Stephanie: Yeah.


Lori Cox: So much for joining us. Thank you, everybody, for joining us on and watch for our next episode of the pulse coming soon.