Hemophilia Clotting Factors: Submitting the Number of Units

When submitting claims for hemophilia clotting factors it is essential to submit the correct Quantity Billed (QB) to receive the correct reimbursement. To calculate the correct QB, divide the number of International Units (IUs) administered by 100 and round to the nearest whole number. This applies to physicians and Ambulatory Surgical Centers billing the following clotting factor procedure codes.

This instruction applies only to the following Healthcare Common Procedure Coding System (HCPCS) codes for hemophilia clotting factors: J7175, J7178,J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7198, J7200, J7201, J7202, J7204, J7205, J7207, J7208, J7209, J7210, J7211 and J7212. 

IMPORTANT: Codes J7169, J7170, J7177, J7196, J7197, J7203 and Q9995 (replaced by code J7170 effective 1/1/2019) are exempt from this special billing process. It has been determined that the dosages for these codes do not warrant the need for special billing requirements. Do not divide billing units by 100 for these eight codes. 

If you experience incorrect payments as a result of the above exceptions, claims will be adjusted as they are brought to our attention.

Providers are reminded to report the number of IUs administered by: 

• First, divide the total number of units given by 100 
• Second, round to the nearest whole number to determine the billing unit 
  • Fractions from .50 to .99 = 1 additional billing unit 
  • Fraction from .01 to .49 = NO additional billing unit 
• Report the result in the units field of the claim form 
• Report the “Total Dosage” in one of the following:
  • Electronic Claims
    • Loop 2300, NTE, 02
    • Loop 2400, NTE, 02 
    • Loop SV101-7
  • Paper Claims
    • Block 19

Note: If billing monthly, report the Monthly Total Dosage. If submitting more than one claim for the monthly dosage, report “Total Monthly Dosage” followed by the dosage units for the specific claim billed. Example 4 below demonstrates how to bill claims for monthly billings when billed on separate claims.

Example 1
A patient received 1,232 IU of Factor VIII. 

• Divide 1,232 by 100 (1,232/100 = 12.32). Round to the nearest whole number (12). 

Example 2
A patient received 25,778 IU of anti-inhibitor coagulant complex. 

• Divide 25,778 by 100 (25,778/100 = 257.78). Round to the nearest whole number (258). 

Example 3 
A patient received 5,798 IU of Factor IX. 

• Divide 5,798 by 100 (5,798/100 = 57.98). Round to the nearest whole number (58). 

Exception: For the “Not otherwise classified” HCPCS code (NOC) J7199, the Quantity Billed is always 1 and requires additional documentation.

This code requires the drug name, dosage (total IUs administered) and NDC. This information should be submitted in Loop/Elem 2400, SV101-7 as this is a required Loop/Elem for NOC codes. If additional space is needed, Loop 2300, or 2400, NTE, 02 can be used for electronic claims. For paper claims, submit this information in Item 19 of the CMS-1500 claim form.

Example 4
First claim submission should report:
Total Monthly Dosage 1500
Claim one of three – 750 units

Second claim submission should report: 
Total Monthly Dosage 1500
Claim two of three — 550 units

Third claim submission should report:
Total Monthly Dosage 1500
Claim three of three — 200 units

Self-Administration of Blood Clotting Factors
Medicare provides coverage for self-administration for blood clotting factors for hemophilia patients competent to use such factors to control bleeding without medical supervision. When billing blood clotting factors for self-administration indicate “Monthly Billing” with your comments.

Important 
If the calculated QB exceeds the total units indicated below for the specific HCPCS code, the reimbursement amount may be calculated incorrectly. That is, the total payment allowance on a single detail line item cannot exceed $99,999.99. In order to ensure that your reimbursement is correct in these instances, split the service onto two detail lines: 

(Note: The following QB recommendations are based on the highest fee amount listed in the tables below. While the recommendations are rounded, QB recommendations could differ based on the specific fees for each quarterly update).

• HCPCS codes J7186, J7183 and J7190: submit up to 800 on a single detail line
• HCPCS codes J7178, J7182, J7185, J7187, J7192, J7193, J7209 and J7211: submit up to 700 on a single detail line 
• HCPCS codes J7192, J7194, J7200 and J7210: submit up to 600 on a single detail line 
• HCPCS codes J7179, J7189, J7191, J7195, J7198, J7204, J7205, J7207, J7208 and J7212: submit up to 400 on a single detail line
• HCPCS codes J7201, J7202 and J7203: submit up to 200 on a single details line
• HCPCS codes J7175, J7180 and J7188: submit up to 100 on a single detail line
• HCPCS code J7181: submit up to 50 on a single detail line
  • For charges that exceed $99,999.99 on a single claim: 
    • If the charges involve multiple dates of service, submit each date of service on a separate claim 
    • If the billed charges are for the same date of service, submit the total charges and units on two separate claims, with the charges and units not being equal 
    • If the charges are for a single date of service and you need to reflect the actual charge on the claim for purposes of a secondary insurer, submit two separate claims as described above. If only one claim is submitted and the total actual charge is submitted in Loop 2300 or 2400 for electronic claims or in Item 19 for paper claims, the claim will be processed with a total charge of $99,999.99. 

 ASP Drug Fee Conversions for Hemophilia Blood Clotting Factor Special Billing Requirements: (Physician Billing) 

ICIC* Payment will be based off published wholesale acquisition cost (WAC) or invoice in the absence of a published WAC.
^* Revised Fee. Adjustments will be made as claims are brought to our attention.
¹ Fee is not subject to special billing. Code is exception to the special billing rules. Do not divide billing units by 100.

Publication of a fee does not imply coverage.

 ASC Drug Fee Conversions for Hemophilia Blood Clotting Factor Special Billing Requirements: (ASC Billing)

^*ICIC Payment will be based off published wholesale acquisition cost (WAC) or invoice in the absence of a published WAC. 

^* Revised Fee. Adjustments will be made as claims are brought to our attention.
¹ Fee is not subject to special billing. Code is exception to the special billing rules. Do not divide billing units by 100.

Publication of a fee does not imply coverage.