Billing and Payment Instructions for A/B MACs (A) (Rev. 3085, Effective: Upon Implementation of ICD-10)

by  Jared Staheli
July 8th, 2015

Claims for the oral anti-emetic drug aprepitant, either as a 3-day supply dispensed in a Tri-Pak or as the first day supply (not dispensed in a Tri-Pak), must be billed to the A/B MAC (A) on the ASC 837 institutional claim format or on hard copy Form CMS-1450 with the appropriate cancer diagnosis and HCPCS code or Current Procedural Terminology (CPT) code.

Claims for the second and third dose of the oral anti-emetic drug aprepitant not dispensed in a Tri-Pak must be billed to the DME MAC.

The following payment methodologies apply when hospital and SNF outpatient claims are processed by the A/B MAC (A):

• Based on APC for hospitals subject to the outpatient prospective payment system (OPPS);

• Under current payment methodologies for hospitals not subject to OPPS; or

• On a reasonable cost basis for SNFs.

Institutional providers bill for aprepitant under Revenue Code 0636 (Drugs requiring detailed coding).

NOTE: Inpatient claims submitted for oral anti-emetic drugs are processed under the current payment methodologies.

Medicare contractors shall pay claims submitted for services provided by a CAH as follows: Method I technical services are paid at 101% of reasonable cost; Method II technical services are paid at 101% of reasonable cost, and, Professional services are paid at 115% of the Medicare Physician Fee Schedule Data Base.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 17