CurrentFlorida BluePolicy N/A

Inpatient Clotting Factor Reimbursement and Billing Medicare Advantage

Defines billing and reimbursement rules for inpatient administration of hemophilia clotting factor products for Florida Blue Medicare Advantage members, directed at hospitals and inpatient providers.

Policy Summary

PayerFlorida Blue

PolicyInpatient Clotting Factor Reimbursement and Billing Medicare Advantage

Policy CodePolicy N/A

Change TypeMinor revision / administrative (no material coverage changes)

Effective Date11/15/2024

Next Review DateN/A

Key ActionReport clotting factor HCPCS with revenue code 636 to qualify for additional inpatient payment; claims billed with revenue codes 250-259 may be denied or reduced.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11/15/2024Policy effective date

ASP+6%Reimbursement basis

636Required revenue code

D66-D68.4Qualifying diagnoses

Medicare AdvantageLines of business

Inpatient Clotting Factor Payment Criteria

Inpatient clotting factor payment criteria

Covered when ALL of the following are met:

ALL of the following

Patient must be an admitted inpatient under the Inpatient Prospective Payment System (IPPS).
The claim must include an ICD-10 diagnosis code in the range D66–D68.4 on the inpatient claim.
Clotting factor HCPCS/NDC units must be reported and billed with revenue code 636; reporting the clotting factor HCPCS with revenue codes 250–259 will result in denial or reduction of the claim.
Reimbursement for qualifying clotting factor products is calculated using CMS published HCPCS/NDC units paid at Average Sales Price (ASP) + 6% per the CMS quarterly ASP pricing files.

Policy Summary

PayerFlorida Blue

PolicyInpatient Clotting Factor Reimbursement and Billing Medicare Advantage

Policy CodePolicy N/A

Change TypeMinor revision / administrative (no material coverage changes)

Effective Date11/15/2024

Next Review DateN/A

Key ActionReport clotting factor HCPCS with revenue code 636 to qualify for additional inpatient payment; claims billed with revenue codes 250-259 may be denied or reduced.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

HCPCS Codes and Reimbursement

HCPCS clotting factor codes (partial list)HCPCSCovered

J7170	Ini_emicizumab-kxwh 0.5 mg
J7199	Multiple clotting factor HCPCS codes listed (see policy for full list)

Reimbursement calculation — ASP + 6% per CMS quarterly ASP files

Reimbursement methodPaid at Average Sales Price (ASP) + 6% based on CMS quarterly ASP pricing files

Basis for calculationUses HCPCS/NDC units and NDC units; calculated separately from IPPS Pricer software

Source of pricing filesCMS publishes reimbursement information for clotting factors quarterly in the ASP pricing files on their website

Applicable lines of businessMedicare Advantage inpatient claims at short-term and long-term care hospitals

Billing Validation and Denial Risks

Denial Risk

Billing Validation — Revenue Code 636 Required

Ensure inpatient hemophilia clotting factor billing uses revenue code 636. Claims submitted with a HCPCS clotting-factor code but billed with an incorrect revenue code (for example, revenue codes 250–259) risk denial or reduction of payment; Florida Blue will deny or partially deny such claims and may request additional information. CMS rules require HCPCS for clotting factor be reported with revenue code 636 and additional payment applies only for admitted patients with an ICD-10 diagnosis in the D66–D68.4 range.

Required revenue code: 636
Incorrect billing examples: revenue codes 250–259 (will be denied or reduced)
Affected claims: inpatient admissions with HCPCS clotting-factor codes
Denial actions: claim denial, partial charge reduction, or request for additional information

Key Terms and Billing Codes

IPPS add-on payment for blood clotting factors — brief definition/key point

DefinitionAdditional inpatient payment under the Inpatient Prospective Payment System (IPPS) for costs of furnishing blood clotting factors to admitted patients with hemophilia

Eligibility requirementApplies only to admitted inpatients with a reported ICD-10 diagnosis code in the range D66–D68.4

Calculation noteThe add-on payment calculation is performed separately from PPS Pricer software using alternate procedure code, units, NDC and NDC units

Revenue code requirement — revenue code 636 required to qualify for additional payment

Required revenue codeRevenue code 636 is required when reporting HCPCS clotting factor codes to qualify for additional inpatient payment

Denial consequenceClaims billed with clotting factor HCPCS codes using revenue codes 250–259 will be denied or payment reduced

CMS rule referenceCMS editing requires HCPCS be reported with revenue code 636 as described in the Medicare Claims Processing Manual