Billing and coding for EXPAREL in 2015: 4 key points for ASCs

Becker's ASC Review recently received a question about billing and coding for EXPAREL from Pacira Pharmaceuticals.

The question was: "I understand CMS is going to stop reimbursing free standing ambulatory surgery centers for this product (EXPAREL). Can you tell me what is being done to combat this unfortunate government regulation occurring 2015?"

Here is the response from Pacira:

Regarding 2015 Reimbursement and the use of EXPAREL:

• In 2014, the Centers for Medicare and Medicaid Services finalized a policy change such that all drugs and biologicals that function as a supply during a surgical procedure — i.e. are used in conjunction or with or at the time of the surgical procedure — now have their reimbursement included in the reimbursement for the surgical procedure.
• Over the last two years, the cost for EXPAREL has been captured in the Medicare data as facilities have billed C9290 – Injection, bupivacaine liposome, 1 mg – whenever EXPAREL was injected during a surgical procedure for a Medicare beneficiary allowing for these costs to be calibrated into the base payment for the surgical procedure where EXPARAL may be used.
• It is essential that hospital outpatient departments and freestanding ambulatory surgery centers continue to bill C9290 – Injection, bupivacaine liposome, 1 mg – whenever EXPAREL is injected during a surgical procedure for a Medicare beneficiary to ensure that the cost of EXPAREL continues to be calibrated into the reimbursement.
• Several private/commercial insurers are recognizing C9290 – Injection, bupivacaine liposome, 1 mg and some are recognizing the unclassified J-code, J3490 and providing separate reimbursement for EXPAREL. Hospital outpatient departments and ambulatory surgical centers need to review their contracts regarding carve-outs or other payment policies for separately payable drugs to make sure that EXPAREL is included.

Background:

As part of the Final Calendar Year (CY) 2014 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized five new categories of Items and Services to be “Packaged” or Included in Payment for a Primary Service. Two of these new categories relate to drugs, biologicals and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure; and drugs and biologicals that function as supplies; when used in a surgical procedure, including skin substitutes. This policy applies to all types of drugs and biologicals that function as supplies during a surgical procedure. EXPAREL is considered part of this group of drugs and biologicals because it is injected immediately after the surgical procedure while the patient is still on the operating room table at the surgical wound site to control postoperative pain.

With regard to EXPAREL, specifically, it has been on "pass-through," status for the last two years, 2013 and 2014, to allow for its costs to be captured and now accounted for and included in the payment for the primary surgical service, effective Jan. 1, 2015. 2015 Medicare payments for hospital outpatient surgical procedures for some of the procedures where EXPAREL has been used have increased by up to 30 percent, possibly due to the additional costs captured when EXPAREL was used and the C-code was billed. Therefore, it is essential that hospital outpatient departments and freestanding ambulatory surgery centers continue to bill C9290 – Injection, bupivacaine liposome, 1 mg – whenever EXPAREL is injected during a surgical procedure for a Medicare beneficiary to ensure that the costs of EXPAREL continue to be accounted for in CMS' annual payment determination process and rate setting for surgical procedures.

Regarding surgical procedures where EXPAREL is used and the patient is covered by private insurance, it is important for hospital outpatient departments and ambulatory surgical centers to review their contracts regarding carve-outs or other payment policies for separately payable drugs and which HCPCS codes should be billed for such drugs as EXPAREL. Some private payers are recognizing C9290 and some are recognizing the unclassified J-code, J3490. Also, some carve-out policies for ambulatory surgical centers require a copy of the invoice for the separately payable drug or biological to be appended to the patient's insurance claim and the drug and total dosage would be identified in the "Remarks," field of the claim form. It is important to contact your payers, directly, to see what their policies are regarding separately payable drugs and biologicals at the beginning of each calendar year.

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