Medicare Compliance & Reimbursement - 2015 Issue 2
Part D Coverage: Clear Your Confusion on Self Administered Drug by Focussing on Your Facility's Guidelines
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Article Overview
This article covers Medicare Part B and Part D coverage issues for self-administered drugs in hospital outpatient settings. It explains the broad CMS guidance used to judge whether a drug is considered part of a covered outpatient service, highlights the role of facility policy and local Medicare administrative contractors, and notes related patient-notice and billing considerations. It is aimed at coders, billers, and compliance staff who need to understand how hospital guidance and payer guidance interact.
Why This Topic Matters
Self-administered drug handling can affect whether a claim is covered, how a facility notifies patients, and how billing is reported. The topic matters because coverage decisions may vary by setting, payer guidance, and local policy.
Article Sections
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Start by Understanding What Medicare Covers
Introduces Medicare coverage concepts for self-administered drugs in hospital inpatient and outpatient settings. Discusses the general framework used to evaluate outpatient drug coverage.
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Know What ‘Integral’ Means
Reviews CMS guidance on the idea of drugs being integral to a procedure or treatment. Summarizes the broad categories of examples used in the guidance.
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Verify Your Facility’s Definition of ‘Integral’
Explains why facility policy and local Medicare contractor guidance may affect how the concept is applied. Discusses the role of payer interpretation and published non-covered drug lists.
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Also Be Versed With What Is Not ‘Integral’
Covers the opposite side of the guidance by describing general categories of drugs that are not treated as part of the covered procedure or treatment. Notes how CMS and related guidance are used to distinguish these situations.
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Make Your Patients Aware of the Differences
Addresses patient-notice practices and billing-related considerations for noncovered drugs. Includes discussion of reporting and communication responsibilities tied to facility policy.
What You Will Learn
- How Medicare coverage is framed for self-administered drugs in hospital outpatient settings
- How CMS guidance discusses the concept of a drug being integral to a service
- Why facility guidelines and local contractor input matter
- How noncovered drug communication and patient notices are handled at a high level
- What general billing and reporting considerations are discussed for these drugs
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Hospital outpatient revenue cycle staff
Modifiers Discussed
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