chris mancill director, global government affairs amgen inc. the role of appropriate coding
TRANSCRIPT
Chris MancillDirector, Global Government AffairsAmgen Inc.
The Role of Appropriate Coding
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Case Study: Coding for a New Product
This session focuses on the important role of coding in obtaining coverage and payment for new product launches
We will review a relevant and recent case study from Amgen's experience
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In advance of launching our new oncology therapeutic for colorectal cancer (Vectibix™ (panitumumab)), Amgen performed a coding assessment to determine potential gaps in coding
Vectibix™ is a novel therapeutic that is administered intravenously by a physician in her or his office or in the hospital outpatient setting
The assessment was comprehensive in focus
Coding across settings of care and payer types
Coding for the product as well as the associated diagnoses and procedures
In some cases, code sets take time to catch up with new products
The goal of our assessment was to ensure that patient access was available once our product launched
Case Study: New Oncology Launch
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Background:Codes Used in Medical Settings
CPT® Current Procedural Terminology
Healthcare Common Procedure Coding System
HCPCS
ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification
NDCs National Drug Codes
Revenue Codes Facility Cost Centers
Current Procedural Terminology (CPT®) codes copyright 2005 American Medical Association (AMA). All Rights Reserved. CPT® is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.
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Results of Our Coding Assessment
CPT® Codes currently exist to describe administration
Miscellaneous code exists at launch; unique codes require application after launch
HCPCS
ICD-9-CM Codes currently exist to describe diagnoses
NDCs Codes assigned upon product approval
Revenue Codes Codes currently exist to describe facility cost centers
CPT © 2005 American Medical Association. All rights reserved.
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Background:HCPCS Coding
J-Codes Unique, Permanent Codes; All Settings; All Payers
Unique, Temporary Codes; Medicare Only1; OPPS Only
C-Codes
Q-CodesUnique, Temporary Codes; All Settings; Medicare Only
NOC CodesMiscellaneous, Permanent Codes; Often Setting Specific; All Settings
1 Some other payers (e.g., some Blue Cross/Blue Shield plans) may accept HCPCS C-codes, but most do not.
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Codes Available at Launch
Two miscellaneous HCPCS codes available upon launch
J9999 (NOC anti-neoplastic) for physician office
C9399 (unclassified drugs or biologicals) for OPPS
Specific HCPCS coding applications to be submitted upon launch
Temporary HCPCS C-code for use under OPPS
Permanent HCPCS J-code
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Access is Available Immediately Upon Launch
The two miscellaneous HCPCS codes permit access to be available immediately upon launch
J9999 (NOC anti-neoplastic) for physician office
C9399 (unclassified drugs or biologicals) for OPPS
The specific HCPCS codes will facilitate access by permitting automating claims processing
Amgen is educating oncologists and their office staff on the use of miscellaneous codes
Using these codes for new products is commonplace
Physicians are familiar with the codes and the process for new products
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Issues to Consider for Other Products Does the product fall into a Medicare benefit category?
If the product is not physician administered, a new HCPCS code may not be necessary.
Does the product similar to others on the market currently?
If so, is a new code warranted?
Is the product’s method of administration novel?
If the route of administration is novel, a new CPT® code for its administration may also be needed.
Is there a diagnosis code for the condition the product treats? Is it sufficiently specific?
If not, a new or revised ICD-9-CM code may be needed.
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Questions?
Chris Mancill
Director Global Government Affairs
Amgen Inc.
(202) 585-9718