Osteoporosis Injections as HHA Benefit

90.1 - Osteoporosis Injections as HHA Benefit (Rev. 10274, Issued: 08-07-2020, Effective: 01-01-2021, Implementation: 01-04-2021) A. Billing Requirements The administration of the drug is included in the charge for the skilled nursing visit billed using TOB 032x. The cost of the drug is billed using TOB 034x, using revenue code 0636. These drugs are paid on a reasonable cost basis, using the provider’s submitted charges to make initial payments, which are subject to annual cost settlement. Coverage requirements for osteoporosis drugs are found in Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, section 50.4.3. Coverage requirements for the home health benefit in general are found in Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, section 30. Drugs that have the ingredient calcitonin are billed using HCPCS code J0630. HCPCS code J0630 is defined as up to 400 units. Therefore, the provider must calculate units for the bill as follows: Units Furnished During Billing Period Units of Service Entry on Bill 100-400 1 401-800 2 801-1200 3 1201-1600 4 1601-2000 5 2001-2400 6 Drugs that have the ingredient teriparatide may be billed using HCPCS code J3110, if all existing guidelines for coverage under the home health benefit are met. HCPCS code J3110 is defined as 10 mcg. Providers should report 1 unit for each 10 mcg dose provided during the billing period. Drugs that have the ingredient denosumab are billed using HCPCS code J0897, if all existing guidelines for coverage under the home health benefit are met. HCPCS code J0897 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provided during the billing period. Drugs that have the ingredients romosozumab-aqqg are billed using HCPCS code J3111, if all existing guidelines for coverage under the home health benefit are met. HCPCS code J311 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provided during the billing period. Drugs that have the ingredient abaloparatide are billed using HCPCS code J3590 (unclassified biologics), if all existing guidelines for coverage under the home health benefit are met. As an unclassified code, HCPCS code J3590 does have not a standard definition for units. Providers should report 1 unit for each 80 mcg dose provided during the billing period. All other osteoporosis drugs that are FDA approved and are awaiting a HCPCS code must use the miscellaneous code of J3490 until a specific HCPCS code is approved for use. B. Edits Medicare system edits require that the date of service on a 034x claim for covered osteoporosis drugs falls within the start and end dates of an existing home health PPS episode. Once the system ensures the service dates on the 034x claim fall within an HH PPS episode that is open for the beneficiary on CWF, CWF edits to assure that the provider number on the 034x claim matches the provider number on the episode file. This is to reflect that although the osteoporosis drug is paid separately from the HH PPS episode rate it is included in consolidated billing requirements (see §10.1.25 regarding consolidated billing). Claims are also edited to assure that if the claim is an HH claim (TOB 034x), the beneficiary is female and that the diagnosis code for post-menopausal osteoporosis is present.