Billing and coding instructions for hemophilia clotting factor products

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Home ► Claim submission guidelines ► Billing and coding instructions for hemophilia clotting factor products

Last Modified: 4/5/2024 Location: FL, PR, USVI Business: Part B

Billing and coding instructions for hemophilia clotting factor products

The instructions below provide detailed billing/coding for hemophilia clotting factor product HCPCS codes J7169, J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7196, J7197, J7198, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, and J7212.

Part B blood clotting factors are priced as a drug/biological under the drug pricing fee schedule. A furnishing fee will be paid for items and services associated with clotting factor.

When submitting claims for hemophilia clotting factors, it is essential to submit the correct quantity billed (QB) to receive the proper reimbursement.

Role of Medically Unlikely Edits (MUEs) in proper billing

MUEs play a role in proper billing/coding when billing for units of service on the same date of service (DOS) for the same HCPCS code. The number of units of service reported on the same DOS for the same HCPCS code cannot have a claim line quantity exceeding the MUE value for that HCPCS code or exceeding 9,999 units per claim line.

Refer to the MUE website external link

for each HCPCS code being billed. The units to bill per claim line can be determined by dividing the total number of “units of service” by the MUE value. However, if this amount is greater than 9,999 then an additional limitation will apply.

Billing instructions when MUE is less than 9,999 units per line

To determine if multiple claim lines should be billed, divide the number of units administered by the MUE value. Round the result to the next whole number. This is the minimum number of claim lines required to bill the drug.

• If reporting more than one line on the claim, modifier (76) (repeat procedure) must be appended to the second and subsequent lines.

• If the claim is for a monthly supply of clotting factor distributed to the beneficiary on the DOS, indicate “monthly supply” and the date span in the narrative of the claim or the electronic equivalent.

• Do not report a date range as the DOS. For additional information on reporting DOS, see section below titled “Date of Service (DOS)”.

Example:

The MUE for procedure code J7193 is 4,000 units per line. If 12,500 IUs were administered on the same DOS, the minimum number of claim lines can be calculated as four (12,500 ÷ 4,000 = 3.125. rounded up to four lines).

Line	Date of Service (From - To)	Procedure Code/Modifier	Unit of Service	Billed Amount
1	05 01 2021 - 05 01 2021	J7193	4,000	$4,520.00
2	05 01 2021 - 05 01 2021	J7193-76	4,000	$4,520.00
3	05 01 2021 - 05 01 2021	J7193-76	4,000	$4,520.00
4	05 01 2021 - 05 01 2021	J7193-76	500	$565.00

Billing instructions when MUE is greater than 9,999 units per line

Due to system limitations, a maximum of 9,999 units of service may be billed on any one claim line. This limitation is applicable in addition to the established MUE limit for the HCPCS code. If the total number of ‘units of service’ exceeds 9,999:

• Divide the total number of units of service by the maximum number of units that can be billed on a claim line to determine the minimum number of claims lines to bill.

If reporting more than one line on the claim:

• Modifier (76) (repeat procedure) must be appended to the second and subsequent lines.

• Do not report a date range as the DOS. For additional information on reporting DOS, see section below titled “Date of Service (DOS)”

Example:

The MUE for HCPCS code J7192 is 22,000 units per line, which exceeds the system limitation of 9,999 units per line. If 22,000 IUs were administered to a beneficiary on the same DOS, then the total number of “units of service’ would be translated to 22,000 (based on the long descriptor, HCPCS code J7192 is per IU). The minimum number of claim lines to report this amount would be calculated as three lines (22,000 ÷ 9,999 = 2.20, requiring three lines as shown below).

Line	Date of Service (From - To)	Procedure Code/Modifier	Unit of Service	Billed Amount
1	05 11 2021 - 05 11 2021	J7192	9,999	$13,489.65
2	05 11 2021 - 05 11 2021	J7192-76	9,999	$13,489.65
3	05 11 2021 - 05 11 2021	J7192-76	2,002	$2,702.70

Billing for Not Otherwise Classified (NOC) codes

This new billing/coding process is not applicable to NOC codes. However, when billing NOC codes, enter the drug name, dosage/units and the National Drug Code (NDC) in the claim narrative or the electronic equivalent. Report the number of units in the quantity billed field as “1.” For more information review the Appropriate use of not otherwise classified codes article.

Dollar amount exceeds $99,999.99

When providing a month supply and the total billed amount exceeds $99,999.99, two claims must be submitted. When billing two claims, ensure the total dollar amounts are different on each claim.

Example:

The MUE for HCPCS code J7201 is 9,000 units per line. The beneficiary received 47,865 IUs of Factor IX (J7201) ($2.28 per unit). The billed amount is $109,132.20 for the same DOS. The claims should be billed as shown below. Note: In reporting more than one line and or more than one claim bill all subsequent lines with modifier 76 (repeat procedure).

Claim one:

Total billed amount is $99,998.52; total units would be 43,859.

Line	Date of Service (From - To)	Procedure Code/Modifier	Unit of Service	Billed Amount
1	06 01 2021 - 06 01 2021	J7201	9,000	$20,520.00
2	06 01 2021 - 06 01 2021	J7201-76	9,000	$20,520.00
3	06 01 2021 - 06 01 2021	J7201-76	9,000	$20,520.00
4	06 01 2021 - 06 01 2021	J7201-76	9,000	$20,520.00
5	06 01 2021 - 06 01 2021	J7201-76	7,859	$17,918.52

Claim two:

Total billed amount is $9,133.68; total units would be 4,006.

Line	Date of Service (From - To)	Procedure Code/Modifier	Unit of Service	Billed Amount
1	06 01 2021 - 06 01 2021	J7201-76	4,006	$9,133.68

Note: Report a narrative description indicating "monthly billing" as well as the total number of units of service and total charge in item 19 of the CMS-1500 claim form or the electronic equivalent.

Date of service

If the factor product is administered within a facility or "incident to" a physician service, the actual date the drug was administered should be reported as the DOS. If the factor product is being billed by a pharmacy to replenish the beneficiary's home supply, the date the drug was shipped should be used as the DOS on the claim.

Modifier 76

If reporting more than one line, it is very important the modifier 76 be used to prevent denials. Subsequent claim lines billed without modifier 76 will be denied as a duplicate submission. Duplicate submission denials may not be resubmitted; but must be submitted as a first level appeal request.

Documentation

The information listed below should be documented in the patient’s medical record and available to the contractor upon request. Prescription must include:

• The diagnosis on a claim must be one of the hemophilia diagnoses codes

• Provider's prescription must include:

• Name of drug

• Concentration (if applicable)

• Dosage to include initiation date, frequency of administration, duration of infusion (if applicable), signature, date, and any other individual state requirements

• Record from the physician's office must include evidence of medical necessity

• Copy of this medical record must be provided on request

Resource: CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, section 30 external pdf file

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