AHA Coding Clinic® for HCPCS - 2004 Issue 4

New drugs, biologicals and radiopharmaceuticals before creation of HCPCS

Effective January 1, 2004, Section 621(a)(1) of the Medicare Modernization Act (MMA) requires CMS to pay 95 percent of Average Wholesale Price (AWP) for an outpatient drug or biological for which a HCPCS code has not been created. As an interim approach, CMS published Transmittal 188, issued on May 28, 2004, instructing hospitals to bill for a drug or biological that is newly approved by the FDA by reporting the National Drug Code (NDC) for the product along with a new HCPCS code, C9399, Unclassified drug or biological. The Outpatient Code Editor (OCE) suspends the claim for manual pricing...

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