Last week I spoke with Valerie Rinkle, MPA, Revenue Cycle Director of Asante Health System on HCPro’s “Self-Administered Drugs: Master Billing Complexities and Avoid Compliance Pitfalls”. With a confusing topic such as self-administered drugs, it was no surprise we received a number of questions during and after the call. With this being a particularly slow week for CMS, I thought it would be a good idea to share some of these questions and answers with you.
I hope you all find these Q&As helpful in your struggle with self administered drugs. We are continuing to seek guidance from CMS on the definition on integral. In the meantime, if you have questions you should contact your MAC for further guidance as recommend by Dr. John McInnes from CMS.
Q: Could it be possible to have a drug that is integral to the service in the case of patient A but be self-administered and not integral in the case of patient B?
A: It is unclear. It depends on whether you are talking about the same procedure and two different patients or two different procedures provided to two different patients. In the first case, it would depend on your definition of integral. If you consider integral to mean needed for every patient for the particular procedure then it would not be possible to have a drug covered as integral for one patient and not covered for another. However, if you consider that integral means required by this patient for this procedure, there could be a case where one patient may need a drug for provision of the procedure that another patient is simply taking on a routine basis. In the first case, it would be covered, and in the second case it would not – however, I think this would be an extremely unusual clinical scenario. On the other hand if you are talking about the same drug given to different patients receiving different procedures, then I do think this may happen more often. In one case the drug might be integral to the procedure either for the particular patient or for every patient, but in other settings it is not integral, but simply something a patient might be taking at home and therefore not covered. For instance, an inhalation drug might be necessary to complete a pulmonary function test, but might also be something a patient could be using at home and might receive while in observation unrelated to the observation. It would be integral to the pulmonary function test and covered, but not integral to the observation and not covered.
Q: Per policy, we do not allow patients to bring their own medications to the hospital. While the patient is in the hospital, we supply the medication, which many times includes self-administerable medication. Can we bill for these products, as they are necessary for the treatment of the patient?
A: If they are integral to the procedure or treatment, you can bill these as covered to Medicare. Otherwise, if they are simply drugs the patients would normally be taking at home, the medications are not covered and would be billed to the patient as non-covered by Medicare.
Q: Per policy, we do not allow patients to self-administer medication, even if it is self-administerable (e.g., insulin, anti-hypertensives). Would these medications still be considered self-administered?
A: Yes, the definition of self-administered relates to the whether the drug is normally self-administered – not how this particular patient takes the drug. The fact that they didn’t self-administer the drug in this particular instance does not change the fact that the drug is self-administered.
Q: How do we bill for drugs given to the patient for their continued use at home?
A: These should be billed to the patient with revenue code 0253. If you bill to Medicare first you should add the HCPCS code A9270 with the -GY modifier so that the remittance advice is returned with patient responsibility and a Medicare summary notice to the patient. However, you are not required to bill these to Medicare first in order to bill the patient.