by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 12th, 2014
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System (OPPS).
The definition of a “Self administered drug” (SAD) is something you would normally take on your own, and generally not covered by insurance unless they are required for a service you are getting. For more information on Self Administered drug determinations visit us here (Click Here) . You can also do a search on Find-A-Code for information on Self Administered Drugs and select Medicare on the “ Show Search Results for:” tool on the left side of your screen.
A drug that is used in the emergency department for treatment may be considered a SAD where the same drug used for an outpatient surgery may be considered packaged into the procedure, so there are some exceptions. You may want to contact your individual payer(s) for additional assistance. The AHA Coding clinic has an article on Self -administered drugs in the Outpatient setting, (Click Here)
If your payer states they will pay for this and there is no Specific drug code available or does not exist you can use the unclassified drug code J3490 (unclassified Drugs) or J3590 (unclassified Biologic).
If you use an Unclassified drug code you must also include the following information in the REMARKS field (BOX 80/ Reserved for local use field or (Box 19) on the claim or on a separate piece of paper.
- Name and strength of the drug Administered
- Drug/Product, Strength and package size produced by a certain drug manufacture.
- Some payers are requiring the cost of the drug for services on or after January 1, 2013 to be listed on the claim as well.
To find the NDC # and the Labelers on Find-A-Code.com under Codes/NDC-National Drug Code sets (Click Here)
For a list of CMS Self-Administered Drug Exclusion list (Click Here). If you are in question, all contractors are required to a list of the injectable drugs that are subject to the self -administered exclusion on their Web site, including the data and rationale that led to the determination.
Keep in mind that if you bill for a Self-Administered drug, and it gets paid for, it may result in an overpayment.