CMS Pub. 100-04, ch. 3, § 20.7.3

Inpatients

(Rev. 12380; Issued:11-24-23; Effective:10-01-22; Implementation:04-01-24)

Section 6011 of Public Law (P.L.) 101-239 amended §1886(a)(4) of the Social Security Act

(the Act) to provide that prospective payment system (PPS) hospitals receive an additional

payment for the costs of administering blood clotting factor to Medicare hemophiliacs who

are hospital inpatients. Section 6011(b) of P.L. 101.239 specified that the payment be based

on a predetermined price per unit of clotting factor multiplied by the number of units

provided. This add-on payment originally was effective for blood clotting factors furnished

on or after June 19, 1990, and before December 19, 1991. Section 13505 of P. L. 103-66

amended §6011 (d) of P.L. 101-239 to extend the period covered by the add-on payment for

blood clotting factors administered to Medicare inpatients with hemophilia through

September 30, 1994. Section 4452 of P.L. 105-33 amended §6011(d) of P.L. 101-239 to

reinstate the add-on payment for the costs of administering blood-clotting factor to Medicare

beneficiaries who have hemophilia and who are hospital inpatients for discharges occurring

on or after October 1, 1998.

A/B MACs (B) shall process non-institutional blood clotting factor claims.

The A/B MACs (A) shall process institutional blood clotting factor claims payable under

either Part A or Part B.

A. - Inpatient Bills

Under the Inpatient Prospective Payment System (IPPS), hospitals receive a special add-on

payment for the costs of furnishing blood clotting factors to Medicare beneficiaries with

hemophilia, admitted as inpatients of PPS hospitals. The clotting factor add-on payment is

calculated using the number of units (as defined in the HCPCS code long descriptor) billed

by the provider under special instructions for units of service.

The PPS Pricer software does not calculate the payment amount. The Fiscal Intermediary

Shared System (FISS) calculates the payment amount and subtracts the charges from those

submitted to Pricer so that the clotting factor charges are not included in cost outlier

computations.

Blood clotting factors not paid on a cost or PPS basis are priced as a drug/biological under

the Medicare Part B Drug Pricing File effective for the specific date of service. As of

January 1, 2005, the average sales price (ASP) plus 6 percent shall be used.

If a beneficiary is in a covered Part A stay in a PPS hospital, the clotting factors are paid in

addition to the DRG/HIPPS payment (For FY 2004, this payment is based on 95 percent of

average wholesale price.) For a SNF subject to SNF/PPS, the payment is bundled into the

SNF/PPS rate.

For SNF inpatient Part A, there is no add-on payment for blood clotting factors.

The codes for blood-clotting factors are found on the Medicare Part B Drug Pricing File.

This file is distributed on a quarterly basis.

For discharges occurring on or after October 1, 2000, and before December 31, 2005, report

HCPCS Q0187 based on 1 billing unit per 1.2 mg. Effective January 1, 2006, HCPCS code

J7189 replaces Q0187 and is defined as 1 billing unit per 1 microgram (mcg).

The examples below include the HCPCS code and indicate the dosage amount specified in

the descriptor of that code. Facilities use the units field as a multiplier to arrive at the dosage

amount.

EXAMPLE 1

HCPCS Drug Dosage

J7189 Factor VIIa 1 mcg

Actual dosage: 13,365 mcg

On the bill, the facility shows J7189 and 13,365 in the units field (13,365 mcg divided by 1

mcg = 13,365 units).

NOTE: The process for dealing with one international unit (IU) is the same as the process

of dealing with one microgram.

EXAMPLE 2

HCPCS Drug Dosage

J9355 Trastuzumab 10 mg

Actual dosage: 140 mg

On the bill, the facility shows J9355 and 14 in the units field (140 mg divided by 10mg = 14

units).

When the dosage amount is greater than the amount indicated for the HCPCS code, the

facility rounds up to determine units. When the dosage amount is less than the amount

indicated for the HCPCS code, use 1 as the unit of measure.

EXAMPLE 3

HCPCS Drug Dosage

J3100 Tenecteplase 50 mg

Actual Dosage: 40 mg

The provider would bill for 1 unit, even though less than 1 full unit was furnished.

At times, the facility provides less than the amount provided in a single use vial and there is

waste, i.e.; some drugs may be available only in packaged amounts that exceed the needs of

an individual patient. Once the drug is reconstituted in the hospital’s pharmacy, it may have a

limited shelf life. Since an individual patient may receive less than the fully reconstituted

amount, we encourage hospitals to schedule patients in such a way that the hospital can use

the drug most efficiently. However, if the hospital must discard the remainder of a vial after

administering part of it to a Medicare patient, the provider may bill for the amount of drug

discarded plus the amount administered.

Example 1:

Drug X is available only in a 100-unit size. A hospital schedules three Medicare patients to

receive drug X on the same day within the designated shelf life of the product. An

appropriate hospital staff member administers 30 units to each patient. The remaining 10

units are billed to Medicare on the account of the last patient. Therefore, 30 units are billed

on behalf of the first patient seen and 30 units are billed on behalf of the second patient seen.

Forty units are billed on behalf of the last patient seen because the hospital had to discard 10

units at that point.

Example 2:

An appropriate hospital staff member must administer 30 units of drug X to a Medicare

patient, and it is not practical to schedule another patient who requires the same drug. For

example, the hospital has only one patient who requires drug X, or the hospital sees the

patient for the first time and did not know the patient’s condition. The hospital bills for 100

units on behalf of the patient, and Medicare pays for 100 units.

When the number of units of blood clotting factor administered to hemophiliac inpatients

exceeds 99,999, the hospital reports the excess as a second line for revenue code 0636 and

repeats the HCPCS code. One hundred thousand fifty (100,050) units are reported on one

line as 99,999, and another line shows 1,051.

Revenue Code 0636 is used. It requires HCPCS. Some other inpatient drugs continue to be

billed without HCPCS codes under pharmacy.

No changes in beneficiary notices are required. Coverage is applicable to hospital Part A

claims only. Coverage is also applicable to inpatient Part B services in SNFs and all types of

hospitals, including CAHs. Separate payment is not made to SNFs for beneficiaries in an

inpatient Part A stay.

B. - A/B MAC (A) Action

The contractor is responsible for the following:

• It accepts HCPCS codes for inpatient services;

• It edits to require HCPCS codes with Revenue Code 0636. Multiple iterations of the

revenue code are possible with the same or different HCPCS codes. It does not edit

units except to ensure a numeric value;

• It reduces charges forwarded to Pricer by the charges for hemophilia clotting factors

in revenue code 0636. It retains the charges and revenue and HCPCS codes for

CWF; and

• It modifies data entry screens to accept HCPCS codes for hospital (including CAH)

swing bed, and SNF inpatient claims (bill types 11X, 12X, 18x, 21x and, 22x).

The September 1, 1993, IPPS final rule (58 FR 46304) states that payment will be made for

the blood clotting factor only if diagnosis code for hemophilia is included on the bill.

Inpatient blood-clotting factors are covered only for beneficiaries with hemophilia. One of

the following hemophilia diagnosis codes must be reported on the claim for payment to be

made for blood clotting factors.

Table 1 - Effective for discharges September 1 1993 through the implementation of

ICD-10

ICD-9-

CM

code

Description

286.0 Congenital factor VIII disorder

286.1 Congenital factor IX disorder

286.2 Congenital factor XI deficiency

286.3 Congenital deficiency of other clotting factors

286.4 von Willebrands' disease

Table 2 - Effective for discharges August 1, 2001 through the implementation of ICD-

10, payment may be made if a diagnosis codes from either Table 1 or Table 2 is reported is

reported:

ICD-9-

CM code

Description

286.5 Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate

effective September 30, 2011)

286.7 Acquired coagulation factor deficiency

Table 3 - Effective for discharges on October 1, 2011, through the implementation of

ICD-10 payment may be made if a diagnosis code from any of Table 1, Table 2 or Table 3 is

reported:

ICD-9-

CM

code

Description

286.52 Acquired hemophilia

286.53 Antiphospholipid antibody with hemorrhagic disorder

286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants,

antibodies, or inhibitors

Effective for discharges on or after the implementation of ICD-10-CM and prior to

October 1, 2022, the following codes are applicable, and payment may be made for blood

clotting factors only if one of the following hemophilia diagnosis codes from the range D66

- D68.4 is reported.

A crosswalk of ICD 9 to ICD10 hemophilia diagnosis codes follows:

ICD-9-

CM Code

Description ICD-10-

CM

Code

Description

286.0 Congenital factor VIII

disorder

D66 Hereditary factor VIII

deficiency

286.1 Congenital factor IX disorder D67 Hereditary factor IX

deficiency

286.2 Congenital factor XI

deficiency

D68.1 Hereditary factor XI

deficiency

286.3 Congenital deficiency of

other clotting factors

D68.2 Hereditary deficiency of other

clotting factors

286.4 von Willebrands' disease D68.0 Von Willebrand's disease

286.5 Hemorrhagic disorder due to

intrinsic circulating

anticoagulants (terminate

N/A

ICD-9-

CM Code

Description ICD-10-

CM

Code

Description

effective September 30,

2011)

286.52 Acquired hemophilia D68.311 Acquired hemophilia

286.53 Antiphospholipid antibody

with hemorrhagic disorder

D68.312 Antiphospholipid antibody

with hemorrhagic disorder

286.59 Other hemorrhagic disorder

due to intrinsic circulating

anticoagulants, antibodies, or

inhibitors

D68.318 Other hemorrhagic disorder

due to intrinsic circulating

anticoagulants, antibodies, or

inhibitors

286.7 Acquired coagulation factor

deficiency

D68.32 Antiphospholipid antibody

with hemorrhagic disorder

286.7 Acquired coagulation factor

deficiency

D68.4 Acquired coagulation factor

deficiency

(Note, ICD-10-CM Code D68.32 (Hemorrhagic disorder due to extrinsic circulating

anticoagulants) is no longer eligible for payment for blood clotting factors effective July 1,

2018; however, payment may be made for blood clotting factors when ICD-10-CM Code

D68.32 is reported on discharges on or after the implementation of ICD-10-CM and on or

before July 1, 2018.)

Effective for discharges on or after October 1, 2022, D68.0 (Von Willebrand’s disease)

is no longer eligible for payment for blood clotting factors; however, payment may be

made for blood clotting factors when ICD-10-CM Code D68.0 is reported on discharges

on or after the implementation of ICD-10-CM and on or before September 30, 2022.

Effective for discharges on or after October 1, 2022, the following codes are applicable, and

payment may be made for blood clotting factors only if one of the following hemophilia

diagnosis codes from the range D66 - D68.4 is reported.

ICD-10-

CM

Code

Description

D66 Hereditary factor VIII deficiency

D67 Hereditary factor IX deficiency

D68.00 Von Willebrand disease, unspecified

D68.01 Von Willebrand disease, type 1

D68.020 Von Willebrand disease, type 2A

D68.021 Von Willebrand disease, type 2B

D68.022 Von Willebrand disease, type 2M

D68.023 Von Willebrand disease, type 2N

ICD-10-

CM

Code

Description

D68.029

Von Willebrand disease, type 2,

unspecified

D68.03 Von Willebrand disease, type 3

D68.04 Acquired von Willebrand disease

D68.09 Other von Willebrand disease

D68.1 Hereditary factor XI deficiency

D68.2 Hereditary deficiency of other clotting

factors

D68.311 Acquired hemophilia

D68.312 Antiphospholipid antibody with

hemorrhagic disorder

D68.318 Other hemorrhagic disorder due to

intrinsic circulating anticoagulants,

antibodies, or inhibitors

D68.4 Acquired coagulation factor deficiency

C. - Part A Remittance Advice

For remittance reporting PIP and/or non-PIP payments, the Hemophilia Add On is included

in the overall claim payment (Provider Reimbursement, CLP04).

If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is

increased in the PLB segment with a PLB adjustment HM. The Hemophilia Add On amount

will always be included in the CLP04 Claim Payment Amount.

For remittance reporting PIP payments, the Hemophilia Add On will also be reported in the

provider level adjustment (element identifier PLB) segment with the provider level

adjustment reason code HM. For remittances reporting PIP payments, the sum of inpatient

claims, CLP04, is backed out at PLB with PI/PA. If an inpatient claim has a Hemophilia

Add On payment, the payment to the provider is increased in the PLB segment with a PLB

adjustment HM.

D. - Standard Hard Copy Remittance Advice

For paper remittances reporting non-PIP payments involving Hemophilia Add On, add a

"Hemophilia Add On" category to the end of the "Pass Thru Amounts" listings in the

"Summary" section of the paper remittance. Enter the total of the Hemophilia Add On

amounts due for the claims covered by this remittance next to the Hemophilia Add On

heading.

The following reflects the remittance advice messages and associated codes that will appear

when processing claims under this policy. The CARC below is not included in the CAQH

CORE Business Scenarios.

Group Code: OA

CARC: 94

RARC: MA103

MSN: N/A

This will be the full extent of Hemophilia Add On reporting on paper remittance notices;

providers wishing more detailed information must subscribe to the Medicare Part A

specifications for the ASC X12 835 remittance advice, where additional information is

available.

See chapter 22, for detailed instructions and definitions.