General Reimbursement Information
Reimbursement for Cathfo®
Activase® information varies based on healthcare
Review general reimbursement information specific to Medicare onlya
This section provides general coding information related to the use of Cathflo and is intended for informational purposes only. Please consult the Centers for Medicare & Medicaid Services (CMS) for specific information and requirements.
The submission and completion of reimbursement- or coverage-related
documentation are the responsibility of the patient and healthcare
provider. Genentech, Inc. and its affiliates make no representations
or guarantees concerning reimbursement for any service or item.
Hospitals use the International Classification of Diseases (ICD) code sets to report medical diagnoses and procedures associated with inpatient stays. As of October 1, 2015, the tenth revision of these codes (ICD-10) replaced the previous ninth revision (ICD-9) codes.
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-10-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. Some payers may require additional coding and patient-specific clinical information to determine coverage and payment for the inpatient stay. Please contact individual private payers as needed to clarify their specific reimbursement policies for Cathflo.
View an illustrative chart to guide you through the billing process applicable for inpatient hospitals.
On claim forms, hospitals use the International Classification of
Diseases (ICD) code sets to report medical diagnoses and Healthcare
Common Procedural Coding System (HCPCS) Level II codes and American
Medical Association (AMA) Current Procedural Terminology
(CPT®b) to report items and procedures provided during
As of October 1, 2015, all claims need to use the tenth revision of the ICD diagnosis codes to report medical diagnoses (ICD-10-CM) in order to receive reimbursement. All codes should be reported on the claim form to the highest level of specificity.
Medicare may require additional coding and patient-specific clinical information to determine coverage and payment for the outpatient visit. CPT codes are 5-digit number codes created by the AMA to designate specific procedures performed.
Certain supplies, services, procedures, and drugs administered to Medicare beneficiaries in the outpatient setting may be reimbursed separately. Reimbursement for Cathflo administered in the outpatient setting is set at Average Sales Price (ASP) plus 6% (except 340B hospitals; 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-10-CM diagnosis codes (see description of coding systems below). Hospitals should be as thorough as possible in coding to ensure appropriate reimbursement.
View an illustrative chart to guide you through the billing process applicable for outpatients.
Reimbursement for Cathflo administered in a physician's office or
freestanding clinic (ie, 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 physicians’ offices and freestanding clinics bill Medicare using the CMS-1500 claim form.
The form must be completed with Healthcare Common Procedure Coding
System (HCPCS) codes and ICD-10-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.
An illustrative chart to guide you through the billing process applicable to a physician's office or a freestanding clinic.
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.
Three-digit codes that providers (physicians, freestanding 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®b) 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, Tenth Edition, Clinical
There are two types of ICD-10-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-10-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 claim form should be supported by a diagnosis code
Please select the appropriate billing code when filing all claims.
Billing codes should be based on diagnosis and the services provided.
The codes most commonly associated with the billing and reimbursement
of Cathflo are given below. We cannot guarantee that use of the
following billing codes will result in reimbursement.c
For further information regarding drug pricing, please refer to the Medicare website.
Correctly coded claim forms facilitate the claims process and decrease the likelihood of having claims denied.
Visit our Resource
Center for a list of downloadable forms, interactive files, and
other documents designed to facilitate successful claim submissions.
Examples of claim forms that you may use when billing for Cathflo are
aPlease contact other payers as needed to clarify their
reimbursement guidelines for Cathflo.
Procedural Terminology (CPT) is a registered trademark of the American
Medical Association. CPT is copyright 2010 American Medical
Association. All rights reserved. No fee schedules, basic units,
relative values or related listings are included in CPT. The AMA
assumes no liability for the data contained herein. Applicable
FARS/DFARS restrictions apply to government use.
CPT five-digit numeric codes, descriptions, numeric modifiers,
instructions, guidelines, and other materials included in this webpage
are copyright 2010 American Medical Association. All rights
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.