Billing FAQ
Cathflo Frequently Asked Questions on Medicare Billing
The following information is for general education purposes only; payment cannot be guaranteed.
General Information
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What is Cathflo? |
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Cathflo is a thrombolytic agent that gives you a viable treatment option for central venous access device (CVAD, also known as CVC) occlusions. A human tissue plasminogen activator (t-PA) produced by recombinant DNA technology, Cathflo allows you to restore catheter function with efficacy, safety, and ease. |
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What is Cathflo indicated for? |
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Cathflo is indicated for the restoration of function to CVCs, as assessed by the ability to withdraw blood. |
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What is the billing code for Cathflo? |
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The billing code, or J code, for Cathflo is J2997, often listed under the generic name Alteplase. This billing code is associated with a 1 mg billing unit. A single billing unit under a J code may not represent the total amount of the drug used. A facility may bill for however many units are administered. |
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What other thrombolytics are FDA-approved for the restoration of function to central venous access devices? |
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Cathflo is the only thrombolytic that is both FDA-approved and marketed for the treatment of occluded catheters.1 |
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What about my uninsured patients? |
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Genentech has established the Access to Care Foundation for each of its marketed products. The program is designed to provide products to patients who are uninsured or rendered uninsured due to payer denial and who meet the program's medical and financial criteria. For information on Genentech's Access to Care Foundation, please visit LyticExperience.com. |
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Where can I go for additional information? |
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CMS's fiscal intermediaries, or local Medicare claims processors for physicians' offices and clinics, have customer service lines that are set up to answer calls on a variety of topics. CMS Web site provides a directory of intermediaries or carriers. Additionally, you may consult your Fiscal Intermediary or Carrier's Web sites for specific information on how to bill for Cathflo. |
Free-Standing Clinics
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How does a free-standing clinic bill Medicare for Cathflo to restore function to central venous access devices? |
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The |
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What is the reimbursement rate for Cathflo when used to restore function to central venous access devices? |
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The national reimbursement rate for Medicare patients receiving Cathflo in a free-standing clinic and physicians' office is set at Average Sales Price (ASP) plus 6% (published quarterly by the Centers for Medicare and Medicaid Services). Genentech cannot guarantee the exact amount of money, if any, your clinic or office will receive. If you need further assistance regarding Medicare or Medicaid reimbursement policies or procedures, please contact your local carrier directly. |
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Where can I go for additional information? |
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CMS carriers, or local Medicare claims processors for physicians' offices, have customer service lines that are set up to answer calls on a variety of topics. From the CMS Web site see "Section I" Part A Intermediaries and Part B Carriers by State. |
Physicians' Offices
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What billing code does a physicians' office use for administration of Cathflo to restore function to a central venous access device (CVAD)? |
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A physicians' office is required to bill using J codes based on the Healthcare Common Procedural Coding System (HCPCS). Each J code has a predetermined billing unit. A single billing unit under a J code may not represent the total amount of the drug used. The |
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What is the reimbursement rate for Cathflo when used to restore function to a central venous access device? |
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The national reimbursement rate for Medicare patients receiving Cathflo in a free-standing clinic and physicians' office is set at Average Sales Price (ASP) plus 6% (published quarterly by the Centers for Medicare and Medicaid Services). Genentech cannot guarantee the exact amount of money, if any, your clinic or office will receive. If you need further assistance regarding Medicare or Medicaid reimbursement policies or procedures, please contact your local carrier directly. |
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What billing code does a physicians' office use/or reimbursement of Cathflo administration to restore function to a central venous access device (CVAD)? |
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Effective beginning January 1, 2008, Medicare |
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Where can I go for additional information? |
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CMS carriers, or local Medicare claims processors for physicians' offices, have customer service lines that are set up to answer calls on a variety of topics. From the CMS Web site see "Section I" Part A Intermediaries and Part B Carriers by State. |
Hospital Outpatients
Ambulatory Payment Classifications (APCs)
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What are ambulatory payment classifications (APCs)? |
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Ambulatory payment classifications (APCs) refer to the reimbursement system that applies to hospitals for the treatment of Medicare beneficiaries who receive medical care in the hospital outpatient setting. An outpatient is typically someone who comes to the hospital and is not admitted to the hospital as an inpatient. APCs are similar to Diagnosis Related Groups (DRG), the Medicare hospital inpatient reimbursement system, in that an episode of care is reimbursed at a fixed amount that is predetermined by the Centers for Medicare and Medicaid Services (CMS) for groups of services. A single patient may be assigned more than one APC code. Note: APC codes are not billing codes. (Please see below for information on billing.) |
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What types of services and patients do APCs affect? |
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APCs affect services delivered to Medicare beneficiaries in the hospital outpatient setting with some exceptions. |
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What is the reimbursement rate for Cathflo when used to restore function to a central venous access device? |
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Effective beginning January 1, 2008, the national reimbursement rate for Medicare patients receiving Cathflo in a hospital outpatient setting is set at Average Sales Price (ASP) plus 5% (published quarterly by the Centers for Medicare and Medicaid Services). Genentech cannot guarantee the exact amount of money, if any, your clinic or office will receive. If you need further assistance regarding Medicare or Medicaid reimbursement policies or procedures, please contact your local carrier directly. |
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How does my hospital bill Medicare for Cathflo in the outpatient setting? |
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A hospital is required to use Healthcare Common Procedural Coding System (HCPCS) J codes when billing drugs used in the hospital outpatient setting, including Cathflo. The J code, combined with any HCPCS codes for services provided, will group to an Ambulatory Payment Classification, which in turn is used to determine the payment rate for the drug and services. Each J code has a defined number of units associated with it. The J code for Cathflo is J2997, which is defined as 1 mg of the product. Hospitals may bill for multiple units of the product, based on the number of milligrams of Cathflo provided to the patient. |
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What billing code does my hospital use for the administration of Cathflo to restore function to a central venous access device in the outpatient setting? |
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Effective beginning January 1, 2008, Medicare contractors in many states recommend that CPT code 36593 be used to bill for catheter clearance. Hospitals should ask the appropriate Medicare contractor and other payers whether this code or another one is to be used to bill for this procedure. |
FDA CBER (http://www.fda.gov/cber/)
