Hospice Billing

Hospice Prescription Drug and Infusion Pump Reporting

With the implementation of CR 8358, hospices are required to report injectable, infusion pump, and noninjectable prescription drugs for the palliation and management of the terminal illness and related conditions on their claims. Both injectable and noninjectable prescription drugs shall be reported on claims on a line-item basis per fill, based on the amount dispensed by the pharmacy. OTC drugs shall not be reported. The reporting requirements are outlined below:

  • Injectable drugs: Report on a line-item basis per fill, using revenue code 0636 and the appropriate HCPCS code, with units representing the amount filled (i.e. if HCPCS description states Q1234 Drug: 100 mg and the fill was for 200 mg, units reported = 2).
  • Noninjectable prescriptions: Report on a line-item basis per fill (based on the amount dispensed by the pharmacy), using revenue code 0250 and the NDC. The NDC qualifier represents the quantity of the drug filled, and shall be reported as the unit measure.
  • Infusion pumps/Infusion pump drugs: Report on the claim, on a line-item basis per pump order and per medication refill, using revenue code 029X for the equipment and 0294 for the drugs along with the appropriate HCPCS.

Reporting National Drug Codes

The NDC is a code set that identifies the vendor (manufacturer), product and package size of all drugs and biologics recognized by the FDA. The three segments of the 11-digit NDC identify the labeler, the product, and the commercial package size. The first set of numbers in the NDC identifies the labeler (manufacturer, repackager, or distributer). The second set of numbers is the product code, which identifies the specific strength, dosage form (e.g., capsule, tablet, liquid) and formulation of a drug for a specific manufacturer. Finally, the third set is the package code, which identifies package sizes and types.In addition to the actual NDC, you will also have to report the qualifier (electronic claims only), the quantity dispensed, and the unit qualifier.

The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) (milligram: ME) or count (unit: UN). Each dispensed dose must be converted into one of these, following the manufacturer’s unit of measure. International units (F2) must be converted to standard measurements (GR, ML, ME and UN). Examples of proper unit measures include:

  • For drugs that come in a vial in powder form that needs to be reconstituted before administration, bill each vial (UN).
  • For drugs that comes in a vial in liquid form, bill in milliliters (ML).
  • For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR or ME).

Below is a chart with the NDC breakdown:

NDC breakdown for 5010 electronic claims

Qualifier + NDC Code + UOM + Quantity
NDC breakdown for FISS/DDE claims

NDC Code + Quantity + UOM
Qualifier N4 (always report N4) NDC (NDC Field) NDC format (5-4-2)
NDC NDC format (5-4-2) Drug unit quantity (NDC Quantity field) Dispensing quantity
Drug UOM Valid unit of measures are:

F2 (international unit)

GR (gram)

ME (milligram)

ML (milliliter)

UN (unit)
Drug UOM (Qualifier field) Valid unit of measures are:

F2 (international unit)

GR (gram)

ME (milligram)

ML (milliliter)

UN (unit)
Drug unit quantity Dispensing quantity    


Hospice Prescription Drug Reporting Table

When reporting prescription drugs on hospice claims, there are differences based on the type of administration. The table below provides information on how to report these drugs. Visit the Centers for Medicare & Medicaid Service for a list of HCPCS available codes. For a list of NDCs available in the FDA NDC directory, please visit the National Drug Code Directory.

Medication Form (method of administration) Revenue Code HCPCS Revenue Code
Units
NDC NDC Quantity NDC Unit of Measure NDC Example
Non-injectable (solution, liquid, suspension) 0250 N/A 1* Required Quantity of solution, liquid, suspension ML 3 ml bottle of Albuterol 0.083% inhalation solution, NDC qty= 3

0.5 ml of Morphine Sulfate 20 mg/ml oral solution, NDC qty= 0.5
Non-injectable
(Cream, Ointment
or Lotion)
0250 N/A 1* Required Quantity of cream, ointment or lotion GR or ME 5 gm tube of cream,
NDC qty= 5

60 ml bottle of 1% lotion, NDC qty = 60
Non-injectable (powder packet) 0250 N/A 1* Required # of vials/bottles UN (administered in powder form) One bottle of Zmax 2gm oral suspension,
NDC qty= 1
Non-injectable (powder – requires reconstitution) 0250 N/A 1* Required Quantity of powder ML 150 ml bottle of Amoxacillin (powder for reconstitution) 250mg/ml, NDC qty= 150
Non-injectable
(tablet, capsule)
0250 N/A 1* Required # of tablets, capsules per fill UN Two Cephalexin 500mg oral capsules,
NDC qty= 2

One Lorazepam 0.5mg oral tablet, NDC qty= 1
Non-injectable (suppository) 0250 N/A 1* Required # of suppositories per fill UN One 25 mg suppository, NDC qty = 1
Non-injectable
(Transdermal Patches)
0250 N/A 1* Required # of patches UN One Duragesic 50mcg/hr patch, NDC qty = 1
Injectable 0636 Required Amount filled based on HCPCS definition (ex. HCPCS=100 mg, fill=200, units reported as 2) N/A N/A N/A N/A
Infusion pump drug 0294 Required Amount filled based on HCPCS definition (ex. HCPCS=100 mg, fill=200, units reported as 2) N/A N/A N/A N/A
* The 0250 revenue code line only requires a valid value (i.e., whole number) because the actual units (quantity) are reported in the NDC field. Providers can report a unit of “1” or any other value that may assist them internally.

 

Tips/Notes on Drug Reporting

  • To determine the appropriate “Medication Form” select the form that reflects the method by which the medication is administered (e.g. an injectable medication that is administered via inhalation is reported as a non-injectable).
  • Solutions or diluents used to mix with prescription drugs (including those used in an infusion pump) are not to be reported. These “fillers” are not prescription drugs.
  • You will have to convert micrograms to a reportable measure (i.e., milligrams or grams) when reporting the NDC.For example, 1 microgram (mcg) is 1000th of a milligram:
    • 1 mcg= 0.001 mg
    • 10 mcg =0.01mg
    • 100 mcg = 0.1 mg
    • 1000 mcg = 1.0 mg
  • For comfort kit/pack, report each prescription drug in the package as indicated above.
  • Do NOT report OTC drugs on the claim. This would include OTC drugs ordered by a physician. Only prescription drugs should be reported on the claim. Per the FDA's Prescription Drugs and Over-the-Counter (OTC) Drugs: Questions and Answers article, prescription drugs are prescribed by a doctor and only obtained through a pharmacy. OTC drugs are drugs that do not require a doctor's prescription and can be bought off-the-shelf in stores.
  • Do not report “S” HCPCS codes as these are non-Medicare codes and should not be on hospice claims.
  • Do not report pass-through item HCPCS codes (C1300-C9899).These codes are for the Outpatient Prospective Payment System (OPPS) only for possible pass-through payments and should not be on hospice claims.
  • The “Q” HCPCS codes (Q0035-Q4116 and Q9951-Q9968) are mostly DMEsupply type codes.There are a couple drugs listed within these Q code sets but please check with your Medicare coder before using any of these codes.

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