(Transmittal 764/1815, CR 1333)

Corrections have been made to the Medicare Hospital Manual and Medicare Intermediary Manual on payment for blood clotting factor administered to hemophilia inpatients. A typographical error was made in Transmittal 751 and 1792 issued in April 2000 by HCFA. In the examples given, the error was an incorrect Form Locator to be used when reporting units.

The following is from section 460.1 of the Medicare Hospital Manual with the corrections indicated in red text.

These prices will be effective for add-on payments for blood clotting factor administered to inpatients who have hemophilia for discharges beginning on or after October 1, 1999 through September 30, 2000.

J7190	Factor VIII (Antihemophilic)	.79 per IU Factor, Human
J7191	Factor VIII (Antihemophilic)	1.87 per IU Factor, Porcine
J7192	Factor VIII (Antihemophilic)	1.03 per IU Factor, Recombinant
J7194	Factor IX (Complex)	.45 per IU
J7196	Other Hemophilia clotting	1.43 per IU Factors (e.g., anti-inhibitors)
Q0160	Factor IX (Antihemophilic)	.97 per IU Factor, purified, nonrecombinant
Q0161	Factor IX (Antihemophilic)	1.00 per IU Factor, recombinant
Q0187	Factor VIIa (Coagulation Fact)	1.19 per MCGs Recombinant

Report one hundred IUs of any of the clotting factors as one unit. (100 IUs - one billing unit.) Therefore, the payment for one billed unit of hemophilia clotting Factor VIII furnished December 1, 1993, is $76.00. One billed unit of Factor IX is $33.00. One billed unit of other hemophilia clotting factors is $102.00.

If the number of units is between even hundreds, round to the nearest hundred. Thus, units of one to 49 are rounded down to the prior 100 and units of 50 to 99 are rounded up to the next 100 (i.e., 1,249 units are entered on the bill as 12; 1,250 units are entered as 13).

In reporting the number of IUs administered, divide the number of IUs administered by 100 and round the answer to the nearest whole number to determine the billing unit. (An answer which includes fractions of .50 to .99 = 1 additional billing unit. An answer which includes fractions of .01 to .49 = no additional billing units.)

The following examples illustrate the correct billing for the different types of clotting factors:

EXAMPLE 1: A patient receives 1,200 IUs of Factor VIII (J7190) on December 1, 1993. The hospital divides the number of IUs administered by 100 to obtain the number of billing units. (1,200 divided by 100 = 12 billing units.) Enter 12 in FL 46 of the HCFA-1450. The payment amount is $912 [12 billing units x $76 (100 IUs x $.76)].

EXAMPLE 2: A patient receives 3,449 IUs of Factor IX (J7194) on January 4, 1994. The hospital divides this number by 100 to obtain the number of billing units. (3,449 divided by 100 = 34.49 billing units.) Round down to the nearest whole number to obtain the billing units, and enter 34 in FL 46. The payment amount is $1,122 [34 billing units x $33 (100 IUs x $.33)].

EXAMPLE 3: A patient receives 5,250 IUs of anti-inhibitors (J7196) (another type of hemophilia clotting factor) on July 6, 1994. The hospital divides the number of IUs administered by 100 to obtain the number of billing units. (5,250 divided by 100 = 52.50 billing units.) The hospital rounds up to the nearest whole number to obtain the billing units, and enters 53 in FL 46. The payment amount will be $5406 [53 billing units x $102 (100 IUs x $1.02)].

EXAMPLE 4: A patient receives 4,850 MCGs of Factor VIIa (Q0187) on November 1, 1999. The hospital divides the number of MCGs administered by 100 to obtain the number of billing units. (4,850 divided by 100 = 48.50 billing units.) The hospital rounds up to the nearest whole number to obtain
the billing units and enters 49 in FL 46. The payment amount is $5,831 [49 billing units x $119 (100 MCGs x $1.19)].

When the number of units of blood clotting factor administered to hemophiliac inpatients exceeds 999,999,949 (report as 9,999,999), report the excess as a second line for revenue code 636 and repeat the HCPCS code. One billion fifty million (1,050,000,000) units are reported on one line as 9,999,999, and another line as 500,001.

Use Revenue Code 636. This requires HCPCS. Continue to bill other inpatient drugs without HCPCS codes under pharmacy.

In order to qualify for the add-on payment for hemophilia blood clotting factor, the claim must contain a hemophilia diagnosis code, either as principal or secondary diagnosis. One of the following ICD-9-CM diagnosis codes must be present on the claim.

Final rule (58 FR 46304) states that payment will be made for blood clotting factor only if there is an ICD-9-CM diagnosis code for hemophilia included on the bill. Since blood clotting factors are only covered for beneficiaries with hemophilia, list one of the following hemophilia diagnosis codes on the bill: