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J-Codes…The Continuing Saga
Ellen ClauhsSenior Medicaid Analyst
Tom SimonsonDrug Rebate Manager
Laura WestbrockSenior Manager, Client Services
Panel Objectives
OverviewKey Issues
Manufacturers StatesExample scenario between J&J and OK
How Data Niche Can HelpQuestions
Overview
What is a J-Code/HCPCS?Healthcare Common Procedure Coding System Outpatient physician-administered drugs
Why are they so challenging?HCPCS are much more generic than NDC’sSingle Source vs. MultisourceUnit conversion issues
What does the DRA require?
Deficit Reduction Act (DRA)
Requires States to collect rebates for outpatient physician-administered drug claims paid by Medicaid, using codes that sufficiently identify manufacturer (NDC).Mandatory Dates
1-1-2006: Single Source, using HCPCS or NDCs1-1-2008 (or earlier): SS and Top 20 Multisource using NDCsStates may apply for extension of time to comply
What This Means for Manufacturers
Increased number of invoices received
Increase in rebates
Increased need for data and validation
Manufacturer Issues
Invoice IssuesOne invoice with J-Code units mixed in with pharmacy unitsSeparate J-Code invoice each quarterLarge number of PQAS Submissions (Prior quarter J-Code Unit resubmissions)
Access to Claims IssuesJ-code claims not always provided to Data NicheSource of information at State for J-code billings may be different from source for pharmacy billingsNo separate explanatory cover letter(s)
Additional Manufacturer Issues
J-Code Claim Field IssuesUnits: unit = dose of drug administeredRx Number: NoneBilled Amount: Not indicative of quantity dispensed – very high dollars compared to allowed amountHow are states getting units to invoice?
HCPCS units and/or CMS/NDC unitsConverted to CMS units or not
Additional Manufacturer Issues
J-Code Claim Field Issues ContinuedPaid Amount: Lots of low reimbursement – TPL, Medicare X-overs (Medicaid only paying 20% of Medicare allowable)Provider ID Number: Can’t link it to a provider name & address without a provider cross-reference file
Additional Manufacturer Issues
Will physicians bill using J-code units or pharmacy-type units per the administered NDC?Will states provide manufacturers with both the J-code and the NDC reported? Will states provide manufacturers with both the captured units and the converted units?
Additional Manufacturer Issues
New CMS Invoice Format (2007Q4)
Additional Reimbursement Columns Medicaid Amount ReimbursedNon-Medicaid Amount ReimbursedTotal Amount Reimbursed
Oklahoma – Current Process
1-1-2006: Began invoicing SS only per OK x-walk table1-1-2008: Began invoicing SS and all MS per OK tables
Only Physician claims required NDC & NDC QtyDelayed Outpatient claims NDC requirement
7-1-2008: Outpatient claims added requiring NDC & Qty
Additional Details:Both Medicaid and Medicare/Medicaid X-over claims invoicedUse NDC and NDC Qty submitted by provider (problems)If no NDC provided:
Medicaid – Claim denied; mfr not invoicedMedicare X-over – Claim paid
SS: Mfr invoiced; Use HCPCS Code & Qty; convert to CMS unitsMS: Mfr not invoiced
Use OK-specified HCPCS tables; updated annually
Oklahoma – Current Process
State Issues
Multisource drugs – crosswalk not systematically updated when drug becomes multisourceMultiple dosage forms – crosswalk not systematically updated when less expensive dosage forms enter market
Review can be time consuming – will be better to have NDC and units submitted on the claim, BUT past and current process will still require crosswalks and conversionsPotential issue – providers MUST bill correctly in order for the conversion to accurately convert the units
Additional State Issues
Conversions from J-codes to actual NDC administered will be much more complex and cumbersome for the states.
Noridian Administrative Services, LLC (NAS) file should help (on CMS Website)
https://www.dmepdac.com/crosswalk/index.html
Resource StrainClaims AnalysisDispute Resolution
Additional State Issues
Additional State Issues
Complicated change for providers to graspComplicated system changeForms – Difficult for provider to properly submit drug info on claim (837P & I, 1500, UB04)Non-pharmacy providers typically do not have a master drug file as a reference340B status – more providers to review and ensure they are being accurately identified from the website and excluded from the rebate invoice
Verification Check ListHCPCS crosswalk to NDC is validConversion applied correctlyProduct not multisourceCrosswalked to appropriate dosage formUnits billed correctly by physicianProvider not PHS
Additional State Issues
Disputes
Can be due to units (conversion or billing errors)Can be due to reimbursed amount
Non-Medicaid reimbursed not availableTPL, Medicare, Co-pay, etc.
Different Fee Schedules Physician (HCPCS) vs. Pharmacy (NDC)
No Rx information included
J-code disputes are more complicated to resolve
Example of REMICADE® Dispute
REMICADE® Treats Various DiseasesRheumatoid Arthritis, Crohn’s, AnkylosingSpondylitis, Psoriatic ArthritisVariable dosing (5mg/kg) & Intervals
REMICADE® Product InfoSupplied as sterile white lyophilized powder for IV infusion. Reconstitute with 10 ml of Sterile Water for Injection. Each single use vial contains 100 mg infliximab.
REMICADE® Product Info (Con’t)NDC 57894-0030-01Infliximab for Intravenous Injection100 mg Single Use VialCMS UOM = Each VialNoridian X-Walk CF Divisor = 10HCPCS Code J1745
1 HCPCS Unit = 10 mg Infliximab Inj10 HCPCS Units x 10 mg = 100 mg = 1 Vial10 HCPCS Units / 10 CF = 1 Vial
Example of REMICADE® Dispute
Real Life Billing Errors
HCPCS Units NDC Units Units Invoiced Correct CMS Units50.00 50.00 50.00 5.00 40.00 0.40 0.40 4.00
100.00 10.00 10.00 10.00 3,000.00 300.00 300.00 3.00
3.00 0.30 0.30 3.00 3,193.00 360.70 360.70 25.00
Example of REMICADE® Dispute
J-Code Rxs in Data Niche
Currently able to identify J-Code claims for 17 states
2 provide separate invoices/data sets3 provide indicator in Rx ID field3 provide indicator in ICN field9 provide indicator in Source Code field
CT, DE, FL, ID, IL, KS, KY, MI, NC, NH, NV, OK, OR, SC, TX, VA, WI
J-Code Rxs in Data Niche
Oklahoma J-Code Rxs in Data Niche
Additional Data Niche Examples
Suggested Claim Level Data Elements
NDCClaim Group – P or HClaim TypeOrig Paid QtrInvoice Cycle QtrProvider No.NPI No.Provider NamePHS ClaimAlias Recipient IDFrom Date of ServiceTo Date of ServiceDate Paid
Internal Transaction NoScript NoRefill CodeDays SupplyHCPCS CodeHCPCS UnitsPaid Claim UnitsCMS Units InvoicedAmount BilledAllowed ChargeMedicaid Amt ReimbNon-Medicaid ReimbTotal Amt Reimb
J-Code Questions for Data Niche?
State Contact:
Milan RaichDirector of Government & Managed Care [email protected]
Judy HooverManager, Data [email protected]
Manufacturer Contact:
Laura WestbrockSr. Manager, Client [email protected]
Conclusion
Communication of billing processes is crucial
Access to claim level data is essential
Product knowledge is key
Data Niche is prepared to work with both states and manufacturers to make this process work!
Questions?