Medicare is likely to cover Venofer® (iron sucrose injection, USP) and its administration when used for its approved indications. In the physician office, Venofer® is approved for the treatment of iron deficiency anemia in adult and pediatric patients 2 years and older with chronic kidney disease. Please refer to the Important Safety Information below and Venofer® Full Prescribing Information.
As of January 1, 2011, Average Sales Price (ASP) plus 6 percent remains the payment methodology for all separately payable drugs administered in physician offices under Medicare.
Insurers of CKD patients not on dialysis including Medicaid and leading private insurers, may also cover Venofer®. Medicaid coverage policies vary from state to state. Private payer coverage policies can vary considerably from one insurer to another and from patient to patient based on specific policy benefits. Some insurers may not have a formal coverage policy for Venofer®.
Proper coding of services provided is critical to ensuring appropriate reimbursement. The National Healthcare Common Procedure Coding System (HCPCS) Panel has granted a specific HCPCS code (also known as J code) for Venofer®.
J1756 Injection, Iron Sucrose, 1 mg
Each 1 mg of Venofer® equals one (1) service unit. When billing for quantities greater than 1 mg, indicate the total amount used as a multiple of service units on the claim form.
- One (1) vial (2.5 mL) or 50 mg equals 50 service units
- One (1) vial (5 mL) or 100 mg equals 100 service units
- Two (2) vials (10 mL) or 200 mg equals 200 service units
Since Venofer® is a single-use vial containing either 50 mg, 100 mg or 200 mg, if less than the entire vial is administered, the remainder must be discarded. Current CMS policy permits billing for the entire vial even if the entire vial is not used, but only if the remainder is discarded and there is documentation that the remainder was discarded. The discarded amount is billed as a second line with the JW modifier. It is not permissible to bill Medicare twice for the same vial.
- Billing for drug administration
- Outpatient Departments
- Physician's Offices
- Dialysis Centers
- National Drug Code (NDC)