There are two product specific J-Codes for billing MIRCERA ®. The appropriate J-Code is based on site of care: HCPCS Code*1 J0887†, Injection, epoetin beta, 1 microgram, (for ESRD on dialysis) HCPCS Code*1 J0888†, Injection, epoetin beta, 1 microgram, (for non-ESRD use) * HCPCS = Healthcare Common Procedure Coding System
Full Answer
How does the process of Medicare billing work?
Billing for Medicare Before we get into specifics with Medicare, here’s a quick note on the administrative process involved. When a claim is sent to Medicare, it’s processed by a Medicare Administrative Contractor (MAC). The MAC evaluates (or adjudicates) each claim sent to Medicare, and processes the claim.
Can a biller bill Medicare for Part C?
Because Part C is actually a private insurance plan paid for, in part, by the federal government, billers are not allowed to bill Medicare for services delivered to a patient who has Part C coverage. Only those providers who are licensed to bill for Part D may bill Medicare for vaccines or prescription drugs provided under Part D.
Why do billers send claims directly to Medicare and Medicaid?
Since these two government programs are high-volume payers, billers send claims directly to Medicare and Medicaid. That means billers do not need to go through a clearinghouse for these claims, and it also means that the onus for “clean” claims is on the biller.
How does the Medicare Administrative Process Work?
Before we get into specifics with Medicare, here’s a quick note on the administrative process involved. When a claim is sent to Medicare, it’s processed by a Medicare Administrative Contractor (MAC). The MAC evaluates (or adjudicates) each claim sent to Medicare, and processes the claim.
Does Medicare cover Mircera?
Do Medicare prescription drug plans cover Mircera? No. In general, Medicare prescription drug plans (Part D) do not cover this drug.
How is Mircera supplied?
MIRCERA® is administered either intravenously or subcutaneously in adult patients and only intravenously in pediatric patients. When administered subcutaneously, MIRCERA® should be injected into the abdomen, arm, or thigh. MIRCERA® is packaged as single-dose prefilled syringes.
What is procedure code J0887?
HCPCS code J0887 for Injection, epoetin beta, 1 microgram, (for ESRD on dialysis) as maintained by CMS falls under Drugs, Administered by Injection .
What is the generic name for Mircera?
Mircera (methoxy polyethylene glycol-epoetin beta) is a man-made form of a protein that is normally produced by the kidneys to help the body produce red blood cells used to treat anemia (a lack of red blood cells in the body).
What is the cost of Mircera?
About Mircera The lowest GoodRx price for the most common version of Mircera is around $220.78, 14% off the average retail price of $258.93. Compare erythropoiesis-stimulating agents.
What is the difference between Epogen and Mircera?
Epoetin alfa (Procrit, Epogen) acts like the hormone we have in our body, whereas Mircera activates the same receptor as the hormone. Mircera lasts longer and doesn't need to be injected as often, but it can't be used for cancer-related anemia.
How do I bill J0885 to Medicare?
Medicare requires a modifier on the J0885 (either EA or EC depending on the indication) & our MAC carrier requires the reporting of the hemoglobin or hematocrit test result. If you're giving it for anemia caused by chemo and/or the neoplasm then use the EA modifier & list the D64. 81 first.
Does Medicare pay for J0881?
Medicare will cover EPO use for this indication in order to avoid transfusions when the patient is symptomatic from the anemia and the pretreatment Hematocrit level is less than 30. The pretreatment Hematocrit level should be obtained within one week of the initial EPO injection.
What is CPT code J0885?
Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.CodeDescriptionJ0885Epoetin alfa, non-esrdJ0887Epoetin beta esrd useJ0888Epoetin beta non esrdQ4081Epoetin alfa, 100 units esrd4 more rows
How often is Mircera given?
Mircera can be administered once every two weeks or once monthly to patients whose hemoglobin has been stabilized by treatment with an ESA (see Table 1). The dose of Mircera, given as a single intravenous or subcutaneous injection, should be based on the total weekly ESA dose at the time of conversion.
Where do you inject Mircera?
MIRCERA can be injected under the skin in the abdomen, arm or thigh; or into a vein. Your doctor will decide which is best for you. Your doctor will carry out regular blood tests to monitor how your anaemia is responding to treatment by measuring your haemoglobin level.
What is the drug Mircera used for?
This medication is used to treat anemia (low red blood cell count) in people with long-term serious kidney disease (chronic kidney disease). It works by signaling the bone marrow to make more red blood cells. Methoxy polyethylene glycol-epoetin beta helps to reverse anemia.
What is the donut hole in Medicare?
In the Donut Hole (also called the Coverage Gap) stage, there is a temporary limit to what Medicare will cover for your drug. Therefore, you may pay more for your drug. In the Post-Donut Hole (also called Catastrophic Coverage) stage, Medicare should cover most of the cost of your drug.
Does Medicare cover prescription drugs?
No. In general, Medicare prescription drug plans (Part D) do not cover this drug. Be sure to contact your specific plan to verify coverage information. A limited set of drugs administered in a doctor's office or hospital outpatient setting may be covered under Medical Insurance (Part B).
What is the treatment for MIRCERA?
MIRCERA ® is indicated for the treatment of anemia associated with chronic kidney disease (CKD) in adult patients on dialysis and adult patients not on dialysis, and pediatric patients 5 to 17 years of age on hemodialysis who are converting from another ESA after their hemoglobin level was stabilized with an ESA.
Is Mircera contraindicated for PRCA?
MIRCERA ® is contraindicated in patients with: Pure red cell aplasia (PRCA) that begins after treatment with Mircera or other er ythropoietin protein drugs. History of serious or severe allergic reactions to Mircera (e.g., anaphylactic reactions, angioedema, bronchospasm, pruritus, skin rash, and urticaria).
What form do you need to bill Medicare?
If a biller has to use manual forms to bill Medicare, a few complications can arise. For instance, billing for Part A requires a UB-04 form (which is also known as a CMS-1450). Part B, on the other hand, requires a CMS-1500. For the most part, however, billers will enter the proper information into a software program and then use ...
What is a medical biller?
In general, the medical biller creates claims like they would for Part A or B of Medicare or for a private, third-party payer. The claim must contain the proper information about the place of service, the NPI, the procedures performed and the diagnoses listed. The claim must also, of course, list the price of the procedures.
What is 3.06 Medicare?
3.06: Medicare, Medicaid and Billing. Like billing to a private third-party payer, billers must send claims to Medicare and Medicaid. These claims are very similar to the claims you’d send to a private third-party payer, with a few notable exceptions.
How long does it take for Medicare to process a claim?
The MAC evaluates (or adjudicates) each claim sent to Medicare, and processes the claim. This process usually takes around 30 days .
Is it harder to bill for medicaid or Medicare?
Billing for Medicaid. Creating claims for Medicaid can be even more difficult than creating claims for Medicare. Because Medicaid varies state-by-state, so do its regulations and billing requirements. As such, the claim forms and formats the biller must use will change by state. It’s up to the biller to check with their state’s Medicaid program ...
Can you bill Medicare for a patient with Part C?
Because Part C is actually a private insurance plan paid for, in part, by the federal government, billers are not allowed to bill Medicare for services delivered to a patient who has Part C coverage. Only those providers who are licensed to bill for Part D may bill Medicare for vaccines or prescription drugs provided under Part D.
Do you have to go through a clearinghouse for Medicare and Medicaid?
Since these two government programs are high-volume payers, billers send claims directly to Medicare and Medicaid. That means billers do not need to go through a clearinghouse for these claims, and it also means that the onus for “clean” claims is on the biller.
How long does it take for Medicare to pay?
Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020.
What to call if you don't file a Medicare claim?
If they don't file a claim, call us at 1-800-MEDICARE (1-800-633-4227) . TTY: 1-877-486-2048. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, you should file the claim.
How to file a medical claim?
Follow the instructions for the type of claim you're filing (listed above under "How do I file a claim?"). Generally, you’ll need to submit these items: 1 The completed claim form (Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB]) 2 The itemized bill from your doctor, supplier, or other health care provider 3 A letter explaining in detail your reason for submitting the claim, like your provider or supplier isn’t able to file the claim, your provider or supplier refuses to file the claim, and/or your provider or supplier isn’t enrolled in Medicare 4 Any supporting documents related to your claim
What is an itemized bill?
The itemized bill from your doctor, supplier, or other health care provider. A letter explaining in detail your reason for submitting the claim, like your provider or supplier isn’t able to file the claim, your provider or supplier refuses to file the claim, and/or your provider or supplier isn’t enrolled in Medicare.
When do you have to file Medicare claim for 2020?
For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020. Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way.
Does Medicare Advantage cover hospice?
Medicare Advantage Plans provide all of your Part A and Part B benefits, excluding hospice. Medicare Advantage Plans include: Most Medicare Advantage Plans offer prescription drug coverage. , these plans don’t have to file claims because Medicare pays these private insurance companies a set amount each month.
Do you have to file a claim with Medicare Advantage?
Medicare services aren’t paid for by Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage. , these plans don’t have to file claims because Medicare pays these private insurance companies a set amount each month.
