REIMBURSEMENT:

Reimbursement and Medicare Coding Support

PRAXBIND was granted NTAP status beginning on October 1, 2016, effective until September 30, 2017.

Hospitals may be granted an additional reimbursement of up to $1,750 by the CMS when PRAXBIND exceeds the Medicare Severity Diagnosis-Related Groups (MS-DRG) payment amount.

Hospital Inpatient Setting

The payment amount will be based on the hospital's costs for the inpatient stay, not on the dosage of PRAXBIND administered.

    • The additional payment is capped at $1,750 per inpatient stay
  • For eligibility, hospitals must bill using the appropriate ICD-10 procedure code. See codes >
  • Hospitals should report their charges for PRAXBIND using revenue code series [025X] (General Pharmacy) on inpatient claims
    • The charges reported by hospitals will affect the total costs of an inpatient stay, which Medicare uses to calculate NTAPs for eligible cases; therefore, it is important for hospitals to report charges for PRAXBIND at appropriate levels and report these charges whenever PRAXBIND is used

Calculating NTAP for PRAXBIND

When applicable, the additional payment will be calculated case-by-case. NTAP reimbursements for inpatient stays shall be limited to the lesser of:

50% of the average NTAP cost, as calculated by the CMS ($1,750 for PRAXBIND)
OR
50% of the hospital's costs in excess of the applicable MS-DRG payment for the case*
=
NTAP reimbursement calculated on a case by case basis, and capped at $1,750

*If the costs of a given case do not exceed the hospital's MS-DRG payment, additional payment for PRAXBIND will not be provided.

Hospital Outpatient Setting

In order to receive separate payment for PRAXBIND within the outpatient setting, hospitals may bill using the below:

  • C-codes can be used only on Medicare hospital outpatient and ambulatory surgical center (ASC) claims. See codes >
  • Most non-Medicare payers may require that PRAXBIND be billed with a miscellaneous J‑code. See codes >
  • Revenue code requirements may vary in the hospital outpatient setting. See codes >
  • CPT code for the PRAXBIND administration procedure will depend on the length of the infusion. See codes >

Summary of Codes

Reimbursement Codes