Reimbursement information

INTRODUCTION
Caring for chronic kidney disease patients requires that physicians, providers,
other healthcare professionals and administrators work closely with third-party
payers to ensure that appropriate reimbursement is provided for medically
necessary healthcare services. American Regent, Inc., is committed to helping
the renal community better understand reimbursement issues. This section
provides general coverage, coding, and reimbursement information that will
help you understand the policies of the Medicare ESRD program and other
payers for Venofer® (iron sucrose injection, USP).
PATIENT ASSISTANCE PROGRAM AND Venofer® REIMBURSEMENT HOTLINE
American Regent, Inc., has created the Venofer® Patient Assistance Program
(PAP) to help improve access to Venofer® for patients who lack health insurance
and cannot afford therapy. To be eligible for the program, patients must completely
lack health insurance, be ineligible for public insurance or financing, and must
meet income and other criteria established by American Regent. American Regent
will replace the Venofer® provided free of charge while the patient is enrolled in the
program.
In addition, American Regent has created a toll-free hotline to help physicians and
other providers understand payers’ coverage and reimbursement policies for
Venofer® and, when necessary, address reimbursement issues. American
Regent’s Venofer® Reimbursement Hotline is available to provide expert assistance
with all types of insurance claims, including Medicare. This service can be
reached at 800-282-7712 between 9 am and 5 pm, ET. Specifically, hotline program
associates assist with the following:
Insurance verifications - Help callers verify payer coverage and reimbursement
policies for Venofer® for specific patients. Program associates will determine
patients’ benefits level and discuss potential billing options.
Billing assistance - Assist callers with filing claims and understanding the
reimbursement policies for Venofer® including researching state-specific
local codes.
Claims appeals - Support callers in appealing denied claims or inadequate
reimbursement for Venofer®.
Patient assistance - Screen individuals with no health insurance who are ineligible
for public assistance for enrollment in a free product replacement program. Afterhours
callers may leave a message, and the call will be returned the following business
day.
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COVERAGE FOR Venofer® (iron sucrose injection, USP)
Medicare covers Venofer® (iron sucrose injection, USP) and related supplies (needles
and syringes) when provided to Medicare-eligible beneficiaries with ESRD on
hemodialysis. Beneficiaries' expenses are subject to Medicare premium, deductible,
and coinsurance requirements. Medicare pays for Venofer® in addition to, and separate
from, the dialysis composite rate in ESRD.
Insurers of CKD patients, including Medicare, Medicaid and leading private insurers,
may also cover Venofer®. Medicare and Medicaid coverage policies can vary from
state to state. Private payer coverage policies can vary considerably from one insurer
to another and from patient to patient based on specific policy benefits. Some
insurers may not have a formal coverage policy for specific dosing regimens of
Venofer®.
CODING FOR Venofer®
Proper coding of services provided is critical to ensuring appropriate reimbursement.
When billing Medicare for hemodialysis patients, dialysis centers use the
Uniform Bill 92 (UB-92) form. Claims may be submitted on paper or electronically;
either way, the same coding rules apply.
Venofer® (iron sucrose injection, USP) received a positive national coverage decision
for that indication by CMS in 2001 and has been assigned a specific HCPCS
Code: J1756.
Venofer® (iron sucrose injection, USP), is available in a preservative free single
dose vial containing 100 mg of elemental iron per 5 mL.
NDC# 0517-2340-10
Each 1 mg of Venofer® (iron sucrose injection, USP) equals one (1) service unit.
For example:
One (1) vial or 100 mg (5 mL) equals 100 service units
Three (3) vials or 300 mg (15 mL) equals 300 service units
Four (4) vials or 400 mg (20 mL) equals 400 service units
Please Note: Venofer® is supplied in 100 mg/5 mL single-use vials, and a single
administration of 100 mg/5 mL of Venofer® represents 100 service units. When
billing, indicate the total amount of drug used as a multiple of service units (1mg = 1
service unit).
HCPCS CODE SHORT DESCRIPTOR LONG DESCRIPTOR
VENOFER® J1756 IRON SUCROSE INJECTION INJECTION, IRON SUCROSE, 1MG
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To identify the revenue center associated with providing Venofer® (iron sucrose
injection, USP), use the following revenue code:
636 Drugs/Detail Code
To bill Medicare for related supplies (needles and syringes), the following HCPCS
and revenue codes are used:
HCPCS Code:
A4656 Needle (any size, for dialysis, each)
A4657 Syringe (with or without needle, for dialysis, each)
Revenue Code:
270 Medical / Surgical Supplies
Please note that only a physician is qualified to make a diagnosis, and the
diagnosis must be documented in the patient's medical record. American Regent,
Inc., does not recommend the use of any specific diagnosis code in any particular
situation.