Q&A: Should We Report Mitomycin When It's Packaged Into the Payment?

September 21, 2016
Medicare Web

Q: Our ophthalmologists are using mitomycin after surgery for many of their patients. Do we need to report a HCPCS code for this since it gets packaged into the surgery procedure? It seems like a lot of effort for no money.

A: OPPS reimbursement for drugs and biologicals is covered in one of three ways: the item has passthrough status, the item has a cost above the packaging threshold and is reimbursed for separately, or the reimbursement is included in the APC payment for the procedure.

Providers should report HCPCS codes for medications that are used even if there is no direct reimbursement for the item. Reporting a HCPCS code provides specificity of what drug and how much of it was used, and should be reported via the claim. This provides crucial information to CMS as they can determine how much that drug/biological cost the hospital. Without a HCPCS code to identify the item, all drug cost goes into a “pot” and an average is calculated for the purposes of rate setting. CMS is dependent on providers reporting the appropriate HCPCS and number of units in order to have information to calculate payment rates.

For mitomycin, CMS has issued a strong reminder in the October update to OPPS (Transmittal 3602) regarding the HCPCS codes available for reporting mitomycin. For topical application during or after ophthalmic surgery, report J7315 (mitomycin, ophthalmic, 0.2 mg) and only if the item has the brand name of Mitosol. Report J7999 (compounded drug, not otherwise classified) for other topical mitomycin. CMS reminds hospitals that HCPCS code J9280 (injection, mitomycin, 5 mg) should not be used to report a topical application. This is an injectable form of the drug and not applicable in this circumstance.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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