January OPPS Update Details New Radiopharmaceutical Billing Instructions

by Valerie A. Rinkle, MPA

Transmittal 3425 for the January 1 OPPS updates, issued December 18, 2015, bears close reading. There are several detailed instructions contained in this transmittal. One such instruction concerns coding of new drugs and the interplay with policy packaged radiopharmaceuticals and contrast media.

Once a new drug is approved by the FDA, hospitals are allowed to report them with HCPCS code C9399. The national drug code (NDC) number and dose should be reported in the remarks field. Until CMS assigns a specific HCPCS code and makes a payment determination, hospitals receive separate payment at 95% of Average Wholesale Price. However, this code should not be used for any new drugs that are policy packaged, including diagnostic radiopharmaceuticals and contrast media.

In this transmittal, CMS introduces newly established HCPCS codes to be used specifically for new radiopharmaceuticals for PET scans. CMS also reminds hospitals of the specific HCPCS codes to be used for new contrast agents and other new radiopharmaceuticals that are policy packaged. Hospitals need to be careful not to use the C9399 code for any policy packaged drugs. This requirement is a nuance that pharmacy staff may not be aware of as they update their pharmacy information systems and the HCPCS and dosage tables that work with the hospital charge master to correctly assign HCPCS, HCPCS-based dosage, NDCs, NDC-based dosage, and pricing. 

Remember that the HCPCS dosage is not the same as the NDC-based dosage, so units often vary.  Use the HCPCS/CPT/revenue code and service units on the claim in the HCPCS units field because they are the basis for reimbursement. NDC units are based upon the numeric quantity administered to the patient and the unit of measurement (UOM). Some clearinghouse products edit the two unit fields and if the billers are not educated, they may be editing units to make them match if they have not been educated on NDCs and NDC unit reporting or holding claims. 

Recall that the Deficit Reduction Act of 2005 required fee-for-service state Medicaid programs to capture and report the NDC for outpatient-administered drugs beginning January 1, 2008, in order for the state to receive federal financial participation. 

Effective August 1, 2012, all outpatient drug claims billed with HCPCS level II codes must include the NDC number, quantity and unit of measure. It is important to share the NDC reporting requirements with your administrative, clinical, and billing staff.