MIR-20007-1AB, January 2007

Medicare Part B Drug Competitive Acquisition Program (CAP): Do Not Bill a Prescription Order Number More Than Once

Provider Types Affected
Physicians participating in the CAP for Part B Drugs and Biologicals

Provider Action Needed

What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) has found some CAP claims are being processed incorrectly when CAP prescription order numbers are reused when billing for CAP drugs.

What You Need to Do
The prescription order number is intended to be a unique identifier, and it should not be reused.

Background
This special edition article is being released by the CMS to provide a clarification on billing for drugs under the CAP for Part B Drugs and Biologicals.

CAP Claims Processing
In order for the CAP vendor’s drug claim to be processed and paid, physicians must submit:

• A corresponding drug administration claim; and
• A no-pay claim line for the drug.

The vendor’s drug claim and the physician’s claim are then matched in the claims processing system by the prescription order number, and the vendor is paid for the drug that was administered.

A physician’s no-pay claim line consists of:

• The CAP drug’s Health Care Procedure Coding System (HCPCS) code,
• A billed amount (which must not equal zero), and
• The number of HCPCS billing units that were administered.

The CAP prescription order number is:

• A unique number generated by the approved CAP vendor;
• Used to match CAP claims in the payment system; and
• Associated with a line on an electronic claim.

CMS has found that some CAP claims are being processed incorrectly due the following:

• Drugs ordered under one, unique prescription order number are being billed on multiple claim lines; and
• The prescription order number is being reused with the modifier 76. (See the Additional Information section of this article for a definition of modifier 76.)

Note: A CAP prescription order number must only be used on ONE claim line. It should not be reused on another claim line on the same claim, and it should not be reused on any other claim.

CAP Billing Example
If a CAP vendor has shipped a drug using one prescription order number but the drug is administered in several doses, the total amount administered should be identified in the number of billing units.

Example:
The approved CAP vendor has shipped 20 Heparin Units of J1642 Heparin Sodium (Heparin Lock Flush) under the prescription order number QXXXJ1642YYYYY. (Note: HCPCS Code J1642 has the descriptor: Inj heparin sodium per 10 u.)

• The patient’s IV lines required two 10 unit heparin flushes during the course of the office visit.
• Since the HCPCS code defines J1642 as 10 Units of heparin and a total of 20 units of heparin were administered, this situation would be:
  • Billed as 2 billing units of J1642 on a line containing a J1 no-pay CAP modifier, and
  • Associated with prescription order number QXXXJ1642YYYYY.

Additional Information
If you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip   on the CMS Web site.

For additional information about CAP billing refer to the billing tip sheet at www.cms.hhs.gov/CompetitiveAcquisforBios/Downloads/cap_billtips.pdf on the CMS Web site.

Physician billing information on the Competitive Acquisition Program (CAP) may be found at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on the CMS Web site.

In addition, you can find MM4064 (MMA- Competitive Acquisition Program (CAP) for Part B Drugs – Coding, Testing, and Implementation) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm4064.pdf on the CMS Web site.

You can also find SE0672 (Clarification of Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0672.pdf on the CMS Web site.

Modifier 76 - Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original service. This circumstance may be reported by adding the modifier 76 to the repeated service.

Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical necessity of the repeat services. The patient’s medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request.

Flu Shot Reminder
Flu season is here! Medicare patients give many reasons for not getting their flu shot, including --”It causes the flu; I don’t need it; it has side effects; it’s not effective; I didn’t think about it; I don’t like needles!” The fact is that out of the average 36,000 people in the U.S. who die each year from influenza and complications of the virus, greater than 90 percent of deaths occur in persons 65 years of age and older. You can help your Medicare patients overcome these odds and their personal barriers through patient education. Talk to your Medicare patients about the importance of getting their annual flu shot--and don’t forget to immunize yourself and your staff.

Protect yourself, your patients, and your family and friends. Get Your Flu Shot.
Remember - Influenza vaccination is a covered Part B benefit. Note that influenza vaccine is NOT a Part D covered drug. For more information about Medicare’s coverage of adult immunizations and educational resources, go to CMS’s Web site: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0667.pdf .

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: SE0677
Related Change Request (CR) # N/A
Effective Date: N/A

Do you have your NPI?
National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/ on the CMS Web site.