Example 8c: Home Infusion Therapy Pharmacy (Adjudicated with HCPCS in Loop 2400 or NDC in Loop 2410)

Example of services from a home infusion therapy pharmacy, which includes the billing for the drugs delivered for administration in the home and where adjudication may be from either HCPCS code found in SV1 or NDC number provided in Loop 2.

SUBSCRIBER/PATIENT: Steve A. Smith

ADDRESS: 15210 Juliet Lane, Libertyville, IL 60048

SEX: M

DOB: 5/1/1943

SUBSCRIBER IDENTIFICATION #: MBRID12345

GROUP #: GRP01020102

DESTINATION RECEIVER: XYZ Receiver

ETIN: 369852758

DESTINATION PAYER: R&R Health Plan

NATIONAL PLAN IDENTIFIER: PLANID1234

SUBMITTER: Quality Billing Service Corporation

ETIN: 587654321

CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801) 726-8899

BILLING PROVIDER/SENDER: Professional Home IV, LLC

ADDRESS: 1500 Industrial Drive, Libertyville, IL 60048

TIN: 10-1234567

NATIONAL PROVIDER IDENTIFIER: 1234567893

CONTACT PERSON AND PHONE NUMBER: Brenda Holly, (801) 999-9999

PAY-TO PROVIDER: Professional Home IV, LLC

ORDERING PROVIDER: Marcus Welby

NATIONAL PROVIDER IDENTIFIER: 1112223338

PATIENT ACCOUNT NUMBER: CLMN012345

DIAGNOSIS: 465.9

CASE: The service for which the predetermination is requested will be provided over a date span from 2/1/2004 to 2/7/2004 for prescriptions that the physician prescribed on 1/30/2004. In this case, the payer needs the drug duration to process the predetermination request.

Provided is ceftriaxone, 2 gm IV, q24h over 7 days for gravity infusion through PICC line to treat an acute upper respiratory infection. 20mls sterile water is the diluent for reconstitution of the ceftriaxone which is compounded into 100ml saline IV mini-bags. Also provided are all administration supplies and the pole necessary for the ceftriaxone infusion. Additionally, provided are all administration supplies, and flushing solutions (sodium chloride and heparin) prepackaged by the manufacturer in pre-filled syringes.

Drug service lines in this example begin after submission of a daily per diem charge of $200 per day of therapy, coded with HCPCS S9500 in the LX*1 service line.

The drugs are coded with HCPCS j-codes and with NDC numbers. The quantity of units for each pair of HCPCS j-code and NDC is not always the same. In HCPCS drug coding, the billed units of measure is described in the specific code description. For NDC coding in home infusion therapy claims, the billed units equal the containers used, e.g. number of vials, number of bags, etc.:

• If the health plan is to adjudicate the drug claim using the provided HCPCS drug code (such as J0696 in LX*2), the plan obtains the charges, unit of measure and quantity billed for the HCPCS drug code from the SV1 segment. While the provider has sent the information of loop 2410, the plan may or may not use it for other purposes.
• However, if the health plan adjudicates the drug claim using loop 2410 information, this means the plan uses charges submitted in SV102 while quantity and unit of measure are obtained from CTP04 and CTP05.While the unit of measure and quantity in SV103 and SV104 are to reflect the units appropriate for the HCPCS drug code description, the plan is not using them for adjudication.
• For example, in the LX*2 service line, 56 HCPCS units of ceftriaxone (HCPCS code of J0696) is billed by the provider for total charge amount of $682.50. Equivalently, the provider is billing 7 units of ceftriaxone (NDC number 00004-1965-01 for Rocephin®). As 00004-1965-01 Rocephin comes in a physical container of 2gm vials, this means that the provider’s charge per vial of Rocephin is $97.50. As the HCPCS description for J0696 is "injection, ceftriaxone sodium, per 250 mg", 8 units if J0696 is equivalent to 1 unit of 00004-1965-01 ceftriaxone 2gm vial.

• As another example, in LX*3 we state much more briefly that billed are 14 vials of sterile water, NDC 63323-0249-10. As each vial contains 10mls of sterile water, 28 units of HCPCS J7051 are billed since the HCPCS description is "sterile saline or water, up to 5 cc". Note: If there had existed a HCPCS drug code for 10mls of sterile water, say code JXXXX for "sterile water, 10 cc", then the solution for LX*3 in the complete example that follows would have instead been:

    LX*3~
    SV1*HC:JXXXX*15.12*UN*14*12**1~
    DTP*472*RD8*20040201-20040207~
    DTP*471*D8*20040130~
    LIN**N4*63323024910~
    CTP****14*UN~
    REF*XZ*2530001~
    NM1*DK*1*Welby*Marcus****XX*1112223338~

• For certain service lines, the HCPCS code submitted is J3490 "unclassified drugs" because there is a lack of clarity as to which of multiple available HCPCS j-codes are to be selected from. As therefore there are multiple occurrences of J3490, payers should not reject occurrences of J3490 because of overlapping dates.
• When J3490 is used (see service lines LX*4, LX*5, and LX*6), specification of amount charged, quantity billed, unit of measure, NDC number and prescription number is similar to the solution provided in the previous example where HCPCS S5000 and S5001 were used in service lines LX*2 through LX*6.
• Service lines LX*2, LX*3 and LX*4 contain the prescription drugs that are elements of the compound. Service lines LX*5 and LX*6 are for non-compounded prescription drugs.

Service lines LX*2, LX*3 and LX*4 contain the drugs that are elements of the compound. Service lines LX*5 and LX*6 are for non-compounded prescription drugs.

The primary purpose of this example is to demonstrate how drugs are billed along with services when provided by a home infusion therapy pharmacy. Billing for the drugs is found in segments #25-64 below.