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General Reimbursement Information

Cathflo may be used to clear occluded catheters in various healthcare settings. The information below is intended to provide an overview of Medicare reimbursement for Cathflo in some of these different settings. The reimbursement information provided is specific to Medicare only; please contact other payers as needed to clarify their reimbursement guidelines for Cathflo.

Genentech cannot guarantee the exact amount of money, if any, your facility will receive. If you need further assistance regarding Medicare or Medicaid reimbursement policies or procedures, please contact your local carrier directly.

Setting of Care

• Inpatient Hospital
• Outpatient Hospital
• Physician Office / Free-Standing Clinic

Inpatient Hospital

Reimbursement for all services, drugs, and supplies administered to Medicare beneficiaries during a single inpatient hospitalization is bundled into a single prospective payment amount. This payment amount is determined by the Medicare Severity Diagnosis Related Group (MS-DRG) system, which classifies patients into clinically cohesive groups that have similar hospital resource use and length of stay. The MS-DRG assignment for each case is based on the combination of ICD-9-CM diagnosis and procedure codes reported on the hospital claim form, the Unified Bill 2004 (UB-04) (see description of coding systems below).

Under the MS-DRG system, Cathflo is not separately reimbursable when administered to Medicare beneficiaries in the inpatient setting. Instead, its cost is intended to be covered by the single MS-DRG payment. To ensure appropriate reimbursement, be sure to accurately code for all patient diagnoses and procedures performed.

Private payers may employ different reimbursement methodologies that may or may not allow for the separate reimbursement of Cathflo when administered in the inpatient setting. Please contact individual private payers as needed to clarify their specific reimbursement policies for Cathflo.

Outpatient Hospital

Certain supplies, services, procedures, and drugs administered to Medicare beneficiaries in the outpatient setting may be reimbursed separately. Effective January 1, 2011, reimbursement for Cathflo administered in the outpatient setting is set at Average Sales Price (ASP) plus 5% (ASP published quarterly by the Centers for Medicare and Medicaid Services).

To bill Medicare for the services provided and supplies furnished to patients, outpatient hospitals use the UB-04 claim form. The form must be completed with revenue codes, Healthcare Common Procedure Coding System (HCPCS) codes, and ICD-9-CM diagnosis codes (see description of coding systems below). Hospitals should be as thorough as possible in coding to ensure appropriate reimbursement.

Physician Office / Free-Standing Clinic

Effective January 1, 2011, reimbursement for Cathflo administered in a physician's office or free-standing clinic (i.e., a clinic that is not operated as part of a hospital) is set at Average Sales Price (ASP) plus 6% (ASP published quarterly by the Centers for Medicare and Medicaid Services).

Both physician offices and free-standing clinics bill Medicare using the CMS-1500 claim form. The form must be completed with Healthcare Common Procedure Coding System (HCPCS) codes and ICD-9-CM diagnosis codes (see description of coding systems below). Physician providers must also list a doctor's order and medical justification (diagnosis) in the patient's chart for the services provided.

Code Descriptions

Depending on the setting of care, certain code systems are used on the patient's claim form to describe the services provided during the healthcare visit.

Revenue Codes

Three-digit codes that providers (physicians, free-standing clinics, hospitals) use to categorize provided services. When completing the UB-04, providers must describe the services related to the Revenue Code used.

Healthcare Common Procedure Coding System (HCPCS) Codes

Five-digit alphanumeric codes that describe provided services. These codes are divided into three levels:

• Level I: Common Procedural Terminology (CPT^®1) codes for physician services
• Level II: Non-physician services and supplies (including injectable drugs) that are not described by CPT codes
• Level III: Local codes assigned by local carriers and fiscal intermediaries when no national codes have been assigned for allowed services

International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM)

There are two types of ICD-9-CM codes:

• Diagnosis codes - Numeric codes that describe the patient's medical condition during their hospitalization. The patient's primary and secondary diagnoses must be present on the UB-04 and CMS-1500 forms. Every service provided to the patient should be supported by at least one ICD-9- CM diagnosis code on the submitted bill.
• Procedure codes - Numeric codes that describe procedures performed during a patient's medical visit. Any procedure code listed on a patient's claims form should be supported by a diagnosis code.