by Jared Staheli
July 9th, 2015
All hospitals, including critical access hospitals (CAHs), bill the appropriate DME MAC for take-home supplies of oral anti-cancer drugs, oral anti-emetic drugs and multi-day supplies of immunosuppressive drugs, as well as the associated supplying fees. All inhalation drugs and the associated dispensing fees are also billed to the DME MAC.
Claims for these take-home drugs are billed on the NCPDP, a HIPAA-compliant telecommunication format specifically designed for drug billing. All entities billing on the NCPDP use the NDC for the particular drug being billed, and list units as multiples of the quantity represented by the NDC. Follow this link to reach the DME MAC version of the NCPDC implementation guide: http://www.cms.hhs.gov/transmittals/downloads/R689CP.pdf.
When beneficiaries come to a hospital outpatient department and have an encounter with a physician or mid-level professional (e.g., a physician assistant or nurse practitioner) during which one or more specimens are collected for laboratory work, treatment is monitored (including anti-cancer drugs, either oral or infused), and a drug is administered, this is considered an outpatient visit. Only when more than a single day’s supply of a drug is dispensed to the beneficiary for take home use are the drugs so dispensed to be billed to the appropriate DME MAC. When only today’s drug(s) is (are) dispensed and other services are rendered in conjunction with the treatment, the entire visit is billed by the hospital to the local A/B MAC (A) When a beneficiary in a hospital or skilled nursing facility (SNF) non-covered stay, or a hospital/SNF inpatient that has exhausted benefits (TOBs 12x or 22x, respectively) is given a covered oral anti-cancer or anti-emetic drug, or a covered immunosuppressive drug, the hospital or SNF bills its regular A/B MAC (A).
Payment to hospitals is dependent on the applicable payment mechanism for the type of hospital (reasonable cost for TEFRA hospitals and CAHs, ambulatory payment classifications (APCs) for hospitals subject to the hospital outpatient PPS (OPPS).
Immunosuppressive drugs and supplying fees provided by a dialysis facility in the State of Washington are billed to and paid by the A/B MAC (A).
Supplying fees and dispensing fees must be billed on the same claim as the drug.