The following questions were submitted by attendees during the most recent Quarterly Drug Coding, Reimbursement, and Pipeline Update Webinar for Q3 2019.
Q: On the “Pricing Updates” slide it shows that the majority of Code Price changes were increases, but the Medicare Allowable ASP price changes showed a majority which were decreases. Why do these not match?
A: First, we must understand the difference in how these rates are determined. Code Prices are based on manufacturer reported Average Wholesale Prices (AWP), which is the pharmaceutical drug industry equivalent to an MSRP. This price does not reflect the price the drug actually sells for, which could be significantly lower. Often times when reimbursement is based off AWP pricing, a discount is set anywhere from 5% – 25%, or more. Medicare Allowable rates are based on Average Sales Price (ASP) using manufacturer reported sales data that is only available to CMS. Typically, reimbursement rates based on ASP would reflect a markup; 6% in the case of Medicare Part B.
Q: How can I identify new codes on my Data File? Does my IT need to do anything special to load these codes?
Q: For J7311 – [Injection, fluocinolone acetonide, intravitreal implant (RETISERT®)] – for Date of Service prior to 10/1/19, should providers bill 1 unit? For a Date of Service on or after 10/1/19, should they bill 59 units?
Q: Is the information that was shown on the reimbursementcodes.com website only updated quarterly with the release of the HCPCS/CPT Codes?
A: No, RJ Health publishes a monthly data update and the website is updated on the first calendar day of each month. All drug (NDC) pricing and clinical data are updated on a monthly basis, despite the HCPCS/CPT code updates being released quarterly. The Alerts and Notifications section in ReimbursementCodes highlights important changes to the website for the current month:
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