Pharmaceutical & Drugs Articles and Resources

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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?

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 ...

Clarify the Complexity Please! NDC Codes and Drug Classification Systems

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 ...

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 ...

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.

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 ...

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...

ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment

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 ...

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 ...

Understanding The Healthcare Fraud Prevention Partnership's Commitment to the Management of Opioid Misuse and Opioid Use Disorder

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 ...

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 ...

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 ...

HIPAA and the Opioid Crisis

by  Wyn Staheli, Director of Content - innoviHealth

HIPAA and the Opioid Crisis guidance released by HHS.

VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D

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 ...

Product Wastage Documentation Requirements and Reporting: Using JW Modifier

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 ...

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 ...

Exceptions to Average Sales Price (ASP) Payment Methodology (Rev. 2437, 01-01-13) Medicare Pub 100-04 Drugs and Biologicals

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 ...

How do I find a HCPCS code for a laxative given to a patient in our office?

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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Proper Coding and Billing for Drugs, Biologicals and Injections 

by  Find-A-Code™

Proper Coding and Billing for Drugs, Biologicals and Injections

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