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    How to Add a New Retina Drug to Your Practice—11 Steps to Get You Started

    By Matthew Baugh, MHA, COT, OCS, OCSR, Academy Manager of Coding and Reimbursement, and Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement
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    Are you about to adopt a new retina drug into your practice? Rigorous planning and careful attention to detail will be key, because mistakes can be costly. The implemen­tation process may seem daunting, but the steps below will help you get started.

    1. Know when (and how) to use the NOC HCPCS codes. When submitting claims, you bill for drugs using HCPCS codes (Healthcare Common Procedure Coding System). But if a HCPCS code hasn’t yet been assigned to the drug, you would use one of the Not Otherwise Classified (NOC) HCPCS codes.

    2. Research payer policies and FDA indications. Understanding payer policies (aao.org/lcds) is key. But in the absence of a published payer policy, the FDA label may provide some guidance for coverage. The drug will not be reim­bursable if you are using it inappro­priately, so make sure you research the drug’s FDA label for its indications and frequency of treatment.

    3. Update your EHR and practice management systems. Add the new drug(s) to your systems’ libraries.

    Add codes for billing and tracking. For each new drug, set your system up with the following: appropriate NOC HCPCS code (e.g., J3490, J3590); National Drug Code (NDC); claim notes (e.g., medication name, dosage, and invoice amount) for item 19 of form CMS-1500 or its Electronic Data Interchange (EDI) equivalent; “usual and customary fees”; and, once it is assigned, permanent HCPCS code.

    You should also set up your practice’s own internal “pseudocode” for a drug and link it to the NOC HCPCS code. This will help you track a drug’s utiliza­tion, reconcile its inventory, and audit its reimbursement, even if you have to use the same NOC HCPCS code for more than one drug.

    Update templates and processes. Update the following: automated scrub edits, chart templates and macros, encounter types, and scheduling tem­plates. Implementing electronic con­sents can help streamline the process for administering new drugs. (For sam­ple consent forms, see www.omic.com/risk-management/consent-forms/.)

    4. Rethink workflow. Adjust work­flow to accommodate the new drug. Streamlining the process for ordering and administering drugs can help reduce errors and save time.

    5. Educate staff and physicians. Training clinical staff on the use and administration of new drugs is im­portant for ensuring patient safety and efficacy, and all staff members should be aware of new treatments and indi­cations. Staff should also know about prior authorization and step therapy requirements, and billing staff should know the fee schedules, payer con­tracts, and what codes to use.

    6. Establish ordering amounts and monitor inventory. Determining the ap­propriate amount of drug to order and monitoring inventory levels can help prevent shortages or overstocking. Es­tablish a system for tracking drug usage and reordering drugs when needed. For tips, see “IVT Drugs: How to Control Costs and Survive an Audit” (Practice Perfect, July 2014).

    7. Monitor claims and denials. Ensure that claims are submitted correctly and in a timely manner. Monitor denials and take corrective action when necessary. Audit payer reimbursements to confirm that you are paid the right amount.

    8. Take advantage of patient as­sistance programs. Confirm with the vendor any eligible patient assistance and copay programs for the new drug. Identify the process for participating in such programs, train the staff on it, and make sure physicians know about it.

    9. Don’t forget your satellite offic­es. All offices should be equipped to handle new drugs, and staff at satellite offices should be trained on the new drugs. Confirm the process of delivery or transportation to all locations.

    10. Educate your patients. Edu­cating patients on the benefits and potential side effects of drugs is important for patient care and adherence to treatment plans. Providing instructions for administration and any necessary precautions will also help prevent adverse events.

    11. Bookmark aao.org/retinapm. Visit the page frequently for updates on the latest resources and regulations.