decisionhealth Newsletters, Answer Books - 2006 Issue 3 (March)
Medicare_Claims_Processing_Manual / Chapter_17 / 20.0
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Article Overview
This article explains a Medicare payment policy section from the Claims Processing Manual focused on drugs and biologicals not paid under cost or prospective payment methods. It is relevant to billing, coding, and reimbursement professionals who need to understand the scope of the policy, the time period covered, the role of CMS pricing files, and the HCPCS identifiers listed in the table.
Why This Topic Matters
It helps readers identify whether a drug or biological falls within the policy framework described in this manual section and understand the operational context used by Medicare contractors and providers for pricing and claims processing.
Article Sections
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Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis
Introduces the Medicare manual section and the overall subject of payment allowance limits for drugs and biologicals. It also references the revision and administrative source material associated with the policy.
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Payment Methodology and Covered Categories
Summarizes the policy framework for the applicable time period and describes the broad categories of drugs and biologicals addressed by the section. It also notes the general approach used for items not covered by the listed special cases.
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Table 1: Percentages of April 1, 2003 AWP for Selected Drugs
Presents the table of HCPCS identifiers and associated percentage values referenced by the manual section. The table is part of the pricing guidance covered by the article.
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CMS Pricing Files and Contractor Processing
Describes how CMS supplies pricing information to carriers, fiscal intermediaries, and DMERCs, and the general role of the single drug pricer file in claims pricing. It also addresses what happens when CMS does not supply a payment limit.
What You Will Learn
- The scope of Medicare payment allowance limits for drugs and biologicals covered by this manual section
- The general categories of items addressed by the policy
- The time period and administrative context covered by the section
- How CMS pricing files relate to carrier, FI, and DMERC processing
- Which HCPCS identifiers are listed in the pricing table
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Medicare claims processors
- Compliance staff
- Pharmacy reimbursement specialists
Codes Discussed
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