MIR-2007- 04A, April 2007

Claims for the Hemophilia Clotting Factor for vonWillebrand Factor, Healthcare Procedure Coding System (HCPCS) Code J7187 (JSM-07291)

This Information applies to all Medicare Fiscal Intermediaries (FI) and Part A and Part B Medicare

Administrative Contractors (A/B MAC)

The Centers for Medicare & Medicaid Services’ (CMS) HCPCS Committee changed one of the codes for hemophilia clotting factors with the January 1, 2007 HCPCS update. Effective January 1, 2007, the following code change is:

Unfortunately, this information was not received early enough in the year to update the appropriate edits in the Fiscal Intermediary Shared System (FISS). Payment for J-code J7187 requires FISS modifications. The earliest FISS can make the changes is the October 2007 Quarterly Release.

CMS is asking providers to omit both the old code, J7188 and the new code, J7187, from inpatient hospital claims. By omitting the new hemophilia clotting factor J-code from their inpatient claims, the hospitals will be able to receive payment for the relevant diagnostic related groups (DRG) and health insurance prospective payment systems (HIPPS) codes for the inpatient stay.

As a result of this problem with the revised code, CMS has developed the following instructions to be used for hospital discharges between January 1, 2007, and production of the October 2007 FISS release:

• Providers shall submit claims for hospital inpatient care [this includes hospitals paid under the inpatient prospective payment system, paid under the long term care prospective payment system, paid under the inpatient rehabilitation facility prospective payment system, and those paid on the basis of reasonable cost (TEFRA hospitals, and critical access hospitals), as well as Indian Health Service hospital inpatient services (actually paid on a DRG basis)] omitting HCPCS code J7187 (or J7188). This does not apply to claims from inpatient psychiatric facilities (IPFs) paid under IPF Prospective Payment System (PPS); IPFs receive a comorbidity adjustment under IPF PPS based on the presence of a hemophilia diagnosis.
• Contractors will return to the provider any initial claims containing HCPCS code J7187.
• Once the provider has received PPS payment for the inpatient claim, the provider is to immediately submit an adjustment request (Type of Bill (TOB) = 117) using condition code D2, this time including HCPCS code J7187. The adjustment claim will remain pending until the system changes are completed.
• FISS expects to complete the system changes for its October 2007 release.

There is no impact on payment of outpatient hospital claims or on any skilled nursing facility claims.

CMS Joint Signature Memorandum (JSM)-07291 (March 13, 2007)