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Oct 24th, 2022
End-Stage Renal Disease Risk Model Updates for 2023
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?
May 18th, 2020
Packaging and Units for Billing Drugs
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...
Mar 26th, 2020
2020 Medicare Part D Coverage Gap (AKA donut hole)
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...
Mar 26th, 2020
Medicare Part D Coverage Gap (Donut Hole) Closes in 2020
by Jared Staheli, MPP
Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.
Jan 23rd, 2019
Everything You need to Know about Drugs
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
Oct 17th, 2018
Wolters Kluwer Drug Pricing
by Find-A-Code™
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Medicare sent out a news release to inform of incorrect reimbursement and correction.
"End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they:
Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and
Contain non-covered charges
After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
Apr 16th, 2018
Indications for Serotypes A and B Botulinum Toxins
by Find-A-Code™
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
by Jared Staheli, MPP
The opioid epidemic continues to ravage communities nationwide. Since 1999, opioid deaths have quadrupled. 91 Americans die every day from opioid overdoses, and these numbers show no signs of declining. To address an epidemic of this magnitude, unprecedented cooperation between all involved parties needs to occur. In January 2017, CMS released a ...
Jan 29th, 2018
Dental and Medical- Controlled Substance Awareness
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
Jan 25th, 2018
Prescription Drug Discount Program
by Wyn Staheli, Director of Content - innoviHealth
Prescription drugs can be quite costly for those who are uninsured or underinsured. Prohibitive costs have been shown to lead to poor patient outcomes because medications are not taken as prescribed. Medicare has taken steps to address this problem with their Medicare Advantage value based plans (see referenced "Medicare Expands Value ...
Jan 24th, 2018
HIPAA and the Opioid Crisis
by Wyn Staheli, Director of Content - innoviHealth
HIPAA and the Opioid Crisis guidance released by HHS.
by Brittney Murdock, QCC CMCS CPC
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ...
Apr 25th, 2016
Drug Pricing Information
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Single Drug Pricer (SDP): Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present, SDP includes the HCPCS Drug pricing file.
Part B Drug pricing is the payment amounts that will be used to pay for Part B covered drugs. The payment ...
by Jared Staheli, MPP
The payment allowance limits for blood and blood products (other than blood clotting factors) that are not paid on a reasonable charge or prospective payment basis, are determined in the same manner the payment allowance limits were determined on October 1, 2003. Specifically, the payment allowance limits for blood and ...
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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 ...
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by Find-A-Code™
Proper Coding and Billing for Drugs, Biologicals and InjectionsLinks and resources by topic.
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Medicare Pharmaceutical Resources
- Aug 15, 2014 - "The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet - Revised
The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet (ICN 905711) was revised and is now available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS – approved independent national Accreditation Organization, as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
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