This Coding Guide has been prepared to assist inpatient hospital facilities (“providers”) in accurately billing for ANDEXXA®, Coagulation Factor Xa (Recombinant), Inactivated-zhzo. This information details our general understanding of the application of certain codes to ANDEXXA. It is the provider’s responsibility to determine and submit appropriate codes, charges, and modifiers for the products and services rendered. Third-party payers may have additional or different coding and reimbursement requirements. Therefore, before filing any claim, providers should verify these requirements in writing with specific payers.
MEDICARE INPATIENT CODING AND PAYMENT (PART A)
- Only one MS-DRG is assigned to a patient for a particular hospital admission, and determined by
ICD-10-CM diagnoses and procedure codes
– Patients who received ANDEXXA during their hospital stay may be assigned to different
MS-DRGs based on these variables
- It is important to use one of the two unique ICD-10-PCS procedure codes that were created
effective October 1, 2016 for the introduction of ANDEXXA:
|XW03372||XW03372: Introduction of Andexanet Alfa, Factor Xa Inhibitor Reversal Agent into Peripheral Vein, Percutaneous Approach, New Technology Group 2|
|XW04372||XW04372: Introduction of Andexanet Alfa, Factor Xa Inhibitor Reversal Agent into Central Vein, Percutaneous Approach, New Technology Group 2|
- CMS has granted ANDEXXA additional NTAP payment up to $14,062.50, effective October 1, 2018
In addition to the MS-DRG payment, NTAP may facilitate an additional payment equal to the lesser of (i) 50% of the cost of ANDEXXA being directly paid for in addition to the MS-DRG payment, or (ii) 50% of the amount by which the costs of the case exceed the standard MS-DRG payment.
Other Reimbursement Considerations: The specifics of coverage may vary by payer and can be specific to the patient’s unique plan. Please reference the individual patient’s plan to determine any applicable coverage requirements. Portola anticipates that coverage will not be available under Medicare Part B and that, because federal financial participation will not be available, state Medicaid agencies may not cover the drug, as well.
† This list is not designed to be a comprehensive list of procedure codes for any given case. Other procedure codes may be appropriate and submitted to payers. Providers are solely responsible for determining the appropriate codes in billing payers. The information provided here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor.
†† Hospitals not reimbursed under the IPPS, including but not limited to critical access hospitals, excluded cancer hospitals, long-term acute care hospitals, Veterans Affairs (VA) hospitals, Department of Defense (DoD) facilities, and hospitals in the state of Maryland, are not eligible to receive add-on payments.