Visante 
A great question has been asked about payer denials when IVPB solutions, NS 100 ml are separately reported on claims. In some cases, the payer may be too loosely interpreting direction from some of the Medicare Administrative Contractors (MACs) with CMS and inappropriately denying the claims. This instruction from Noridian is an example where the Local Coverage Article (LCA) discusses billing for “hydration services” and contains: “If the fluid is used as the diluent to mix the drug (i.e. the fluid is the vehicle in which the drug is administered)” as a non-billable scenario.” However, this is saying that you can’t bill a “hydration” charge (which is a drug administration charge). It isn’t saying that you can’t bill the NS 100 ml as a drug. Here’s the LCA reference: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=54635&Cntrctr=361&ContrVer=1&CntrctrSelected=361.
If a payer is denying a charge based upon this language in the LCA, we believe that is a misinterpretation of the CMS instructions.
Some practice sites, use USP nomenclature guidelines and put these definitions into policies. A “diluent” can be defined as an amount of NS, SWI, BSWI or other special formulation that is used to reconstitute a powder into a liquid formulation. So the 10 ml of NS that you would use to “dilute” a cefazolin 1 gram vial would not be billed as a “diluent”, but the D5W 100 ml would be billed as a “vehicle” if it was further diluted.
The USP nomenclature guidelines are clear that what we are discussing “vehicles”. When the drug is commercially available in a highly diluted solution (e.g. dobutamine in D5W 250ml), the 250ml is considered a “vehicle”. CMS does not have any instructions on whether a “vehicle” is charged separately, but since they are FDA-labeled as drugs and CMS requests that all drugs be separately reported regardless of payment status, we chose to report them separately on the claims. The USP definitions are in this document:
https://www.usp.org/sites/default/files/usp/document/usp-nomenclature-guidelines.pdf.
A colleague reminded us that you may encounter other reasons that an IVPB charge is rejected by a payer. Many years ago we had difficulty as some of the manufacturers of the “mix-o-vial” IVPB bags did not report the NDC numbers into all payers, so they were rejected as an invalid NDC number. Another scenario may be the “wrong” HCPCS code. Some of these fluids have multiple HCPCS codes based upon the size of the bag and a payer may only recognize one HCPCS code for all sizes. Using Normal Saline as an example, HCPCS code J7030 is reported for Normal Saline Infusion, 1000 cc, J7040 is reported for Normal Saline Infusion, sterile (500 ml= 1 unit), and J7050 is reported for Normal Saline solution, 250 cc. Some payers may only recognize HCPCS code J7050 and require billing units of “4” when a NS 1000 ml is administered.
SHOUT-OUTS
1. The Denials team should get specific information from the payer if IVPB charges are being denied as CMS requests that all drugs be separately reported regardless of payment status.
2. Some IVPB Denials may be the result of unreported NDC numbers or payer-specific instructions to only report one HCPCS code when there are multiple HCPCS codes for different dosage sizes.
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