CMS Issues Rules for Advate Billing

The Centers for Medicare and Medicaid Services (CMS) has published instructions for billing for Advate, an injectable drug used to help ease blood clotting in patients with Hemophilia A. CMS requires that providers bill Advate under HCPCS code J7192.

Providers who use this code will be paid more accurately. Previous codes were generic to cover multiple drug treatments.

The CMS instructions apply to fee-for-service (FFS) Medicare claims submitted by hospitals, physicians, providers and independent facilities that treat patients with end-stage renal disease.

CMS has instructed FFS intermediaries and carriers to deny claims if providers bill for Advate under J3490, J3590 or J7199.

The new code went into effect on July 25, 2004.

Advate is paid under the outpatient prospective payment system (OPPS) at the latest OPPS Pricer. For additional details about the OPPS Pricer, visit the CMS Web site at www.cms.hhs.gov/providers/hopps/.

Payment for blood clotting factors is at 95 percent of Average Wholesale Price (AWP) in the published compendia as of September 1, 2003.

The payment limit for Advate is paid on Type of Bills 12x, 13x, 14x, 22x, 23x, 34x and 72x for independent facilities.

Please note that CMS will not pay for hemophilia clotting factors unless they are accompanied by condition code 07.

For more information, contact a Humana customer service representative at
1-800-4-HUMANA (1-800-448-6262).