Lexiscan Reimbursement
The following is taken from personal correspondence from a reimbursement specialist:
"When billing Astellas' new product to Medicare it will
be coded and reimbursed in differing ways dependent on the patient
setting. In the freestanding facility and physician office
setting, HCPCS code J3490 (Unclassified Drugs) should be billed for
the product. The HCPS code is only to be used when there is no
distinct HCPCS code for the drug being administered, as will be the
case for Lexiscan until a code can be obtained by the manufacturer.
Whenever J3490 is used, the claims must include the name of the
drug, and any pertinent information such as dosage and route of
administration. In this patient setting, Medicare has stated
they will reimburse the product at acquisition cost plus 6%;
facilities should be prepared to furnish copies of invoices upon
request.
"In the hospital outpatient setting, Lexiscan will be billed
with HCPCS C9399 (Unclassified Drugs or Biologicals); when billing
this code facilities will need to also report the National Drug Code
(NDC) for the product, the quantity of drug administered, in the
unit of measure applicable to the drug, and the date the drug was
administered. The payer will manually price the drug at 95% of
Average Wholesale Price (AWP); the NDC for Lexiscan is 0469-6501-89.
"When Billing Lexiscan to private third-party payers
such as Aetna/USHealthcare or United HCPCS code J3490 should be
billed in all patient settings and reimbursement will be per
contract."
