CMS Implements New Code G0498 Affecting Chemotherapy Services for Home Infusion Billing
By: Jeanne Lugli, General Manager, Mediware Reimbursement Services
Until recently, many providers of chemotherapy delivered the drugs, supplies, and equipment to clinics or physicians’ offices because treatment often started in outpatient settings due to the pre-medications required. Once this phase was complete, patients continued prolonged chemotherapy treatments in their homes. Infusion providers then billed for the drugs, supplies and equipment related to the prolonged infusion services directly to the Medicare DME MAC and were reimbursed. Now, for services provided to Medicare beneficiaries, the rules have changed, and if you are not aware of this complete about-face in payment policy, your revenue may be seriously impacted.
Effective today, October 3, 2016, the new G0498 code for chemotherapy with extended home infusion through a pump is classified by CMS as “chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living) using a portable pump provided by the office/other outpatient setting, includes follow up office/other outpatient visit at the conclusion of the infusion.” This billing change is retroactively effective for dates of services on and after January 1, 2016.
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This means that, in addition to billing an all-inclusive fee that encompasses the initiation and termination of the prolonged infusion, as they always have, physicians or clinics must now bill for an all-inclusive fee that encompasses the above services plus the supplies and equipment that had previously been billed directly to Medicare by the home infusion provider. In other words, to continue to provide these services, each home infusion provider will need to create a “pass-through” billing arrangement with physicians or clinics for infusions initiated in outpatient settings. Note that all drugs are billed separately to the A/B MAC.
This change currently impacts Medicare Part B patients; however, infusion pharmacies should be on the lookout for possible changes with their Medicare replacement plans (also known as Medicare Part C) because this directive could trickle down to these plans as well. Therefore, if you are an infusion provider, consider your patient population and identify patients who may be impacted by this new code. You can get an overview from CMS here.
Here are some additional details on the billing changes.
Minimum requirements to bill Medicare Part B (excludes where the services are initiated and disconnected):
- Provider must be a pharmacy.
- Pharmacy must dispense the drug (in order to bill for supplies and pump rental).
- Patient must meet the requirements for chemotherapy at home.
- Patient must be on a prolonged infusion of 8 hours or more, infused via a pump (typically an ambulatory infusion pump).
Chemotherapy initiated and discontinued in the home setting:
- As long as patient meets all coverage criteria, your Medicare reimbursement should remain the same.
- Unless the patient is home bound and you are a certified agency, you will NOT be reimbursed for the nurse time to initiate and disconnect the patient.
NOTE: You are STRONGLY encouraged to validate the CPT code(s) that physicians/clinics use to bill for pre-medication. They cannot use 96416 or any other code that mentions prolonged infusion. If they use this code to bill for their services, this WILL BE considered “double-dipping,” and you are at the same risk as if the treatment was initiated in physician offices or clinics.
Chemotherapy initiated and discontinued at a physician office or outpatient clinic:
- Minimum requirements above must be met and patient must meet all Medicare guidelines for coverage.
- You have two options for billing:
- You can develop an arrangement with physicians/clinics to continue to provide the same services, but rather than bill Medicare directly, you bill the physician/clinic. (You will need to negotiate with each physician/clinic with which you work on pricing for the services you provide.)
- The physicians/clinics bill the A/B MAC with the newly created code, G0498. The rate is supposed to be sufficient to cover physician/clinic fees plus the rental and supplies. This code has an effective date of January 1, 2016 but an implementation date of October 3, 2016.
Billing the DME MAC (A, B, C, or D based on physical location):
- Bill as you always have in the past.
- The physicians/clinics CANNOT bill for any CPT codes that reference prolonged infusion. If they do, Medicare will not allow the home infusion provider to also bill for the pump, supplies, etc. Recommend that physicians/clinics use other codes that match the services they provide to pre-medicate patients prior to prolonged home infusions.
Billing clarification on G0498 code:
The effective date is retroactive to January 1, 2016, but the implementation date is October 3, 2016. Thus, Medicare cannot accept claims with this code prior to October 3. The temporary code that can be used until G0498 is accepted from the local A/B MAC is 96549 (unlisted chemotherapy procedure). If this code is billed (by physicians or clinics), they will need to add a narrative in item 19 of the CMS-1500 or electronic equivalent that states, “96416 plus pump.” This will ensure reimbursement at the rate equal to 96416 plus an additional amount for pump rental. The drugs are always separately billable.
Although sorting out the new rules for billing prolonged chemotherapy may prove challenging, Mediware Reimbursement Services proactively manages billing changes such as these with staff that have been in the infusion industry for more than 30 years. See how you can streamline your home infusion billing and eliminate billing headaches with Mediware Reimbursement Services today!