January 2007
Provider Types Affected
Physicians participating in the CAP for Part B Drugs and Biologicals
Provider Action Needed
A CAP prescription order number must only be used on one claim line. It should not be reused on another claim line on the same claim, and it should not be reused on any other claim.
The Centers for Medicare & Medicaid Services (CMS) has found some CAP claims are being processed incorrectly when CAP prescription order numbers are reused when billing for CAP drugs. The prescription order number is intended to be a unique identifier, and it should not be reused.
Background
This special edition article is being released by the CMS to provide a clarification on billing for drugs under the CAP for Part B Drugs and Biologicals.
CAP Claims Processing
In order for the CAP vendor's drug claim to be processed and paid, physicians must submit:
The vendor's drug claim and the physician's claim are then matched in the claims processing system by the prescription order number, and the vendor is paid for the drug that was administered.
A physician's no-pay claim line consists of:
The CAP prescription order number is:
CMS has found that some CAP claims are being processed incorrectly due the following:
Note: A CAP prescription order number must only be used on ONE claim line. It should not be reused on another claim line on the same claim, and it should not be reused on any other claim.
CAP Billing Example
If a CAP vendor has shipped a drug using one prescription order number but the drug is administered in several doses, the total amount administered should be identified in the number of billing units.
Example:
The approved CAP vendor has shipped 20 Heparin Units of J1642 Heparin Sodium (Heparin Lock Flush) under the prescription order number QXXXJ1642YYYYY. (Note: HCPCS Code J1642 has the descriptor: Inj heparin sodium per 10 u.)
Additional Information
If you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website.
For additional information about CAP billing refer to the billing tip sheet at www.cms.hhs.gov/CompetitiveAcquisforBios/Downloads/cap_billtips.pdf on the CMS website.
Physician billing information on the Competitive Acquisition Program (CAP) may be found at http://www.cms.hhs.gov/CompetitiveAcquisforBios/02_infophys.asp on the CMS website.
In addition, you can find MM4064 (MMA- Competitive Acquisition Program (CAP) for Part B Drugs – Coding, Testing, and Implementation) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/mm4064.pdf on the CMS website.
You can also find SE0672 (Clarification of Requirements for the Competitive Acquisition Program (CAP) for Part B Drugs and Biologicals) at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0672.pdf on the CMS website.
Modifier 76- Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original service. This circumstance may be reported by adding the modifier 76 to the repeated service.
Note: When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The repeat service should be reported on the next line with modifier 76 appended to the procedure code. In the event it is medically necessary to repeat a procedure more than twice, report the second line with the 76 modifier and the appropriate number of units in the units field. If a service is repeated more than once, additional documentation should be provided in the narrative field of the claim to support the medical necessity of the repeat services. The patient's medical records must always document the medical necessity of performing repeat procedures and be available to the carrier upon request.
CMS Special Edition Article SE0677