( se1609)

Disclaimer This article was prepared as a service to the public and is not  intended to grant rights or impose obligations. This article m ay contain references or links to statutes , regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and acc urate statement of their contents. CPT only copyright 2015 Amer ican Medical Association.   Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services   MLN Matters Number: SE1609 Related Change Request (CR) #: N/A Related CR Release Date: N/A Effective Date: N/A Related CR Transmittal #: N/A Implementation Date: N/A Medicare Policy Clarified for Pro longed Drug and Biological Infusions Started Incident to a Physician's Service Using an External Pump  Note:  We revised this article on June 6, 2019, to update the web link s. All other information is unchanged. Provider Types Affected This MLN Matters Special Editi on article is intended for all physicians and hospital outpatient departments submitting claims to Medicare Administrative Contractors (MACs) for prolonged dr ug and biological infusions started inci dent to a physician's service using an external pump. Note that this article does not apply to suppliers claims submitted to Durable Medical Equipment MACs ( DME MACs). What You Need to Know Medicare pays for drugs and biol ogicals which are not usually self-administered by the patient and furnished inci dent to physicians services re ndered to patients while in the physicians office  or the hospital outpatient depa rtment.  In some situations, a hospital outpati ent department or physician office may:  Purchase a drug for a medicall y reasonable and necessary prolo nged drug infusion,  Begin the drug infusion in the care setting using an external pump,   Send the patient home for a portion of the infusion, and   Have the patient return at t he end of the infusion period.   MLN Matters Number: SE1609 Relat ed Change Request Number: N/A  Disclaimer This article was prepared as a service to the public and is not  intended to grant rights or impose obligations. This article m ay contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and othe r interpretive materials for a full and accurate statement of their contents. CPT only copyr ight 2015 American Medical Association.    Page 2 of 3 In this case, the drug or biologi cal, the administration, and the external infusion pump is billed to your MAC . However,  because prolonged drug and biological infusions started incident to a physician's service using an external pump should be treated as an incident to service, it cannot be billed on suppliers claims t o DME MACs.  Background Under section 1861(s)(2)(A) of the S ocial Security Act (the Act ), Medicare will pay for drugs and biologicals which are f urnished incident to a physi cians professi onal service.  Under section 1861(s)(2)(B) of the  Act, Medicare will pay for d rugs and biologicals which are not usually self-administer ed by the patient furnished as incident to physicians services rendered to outpatients.  In order for Medicare to pay  for a drug or biological under section 1861(s)(2)(A) or (B) of t he Act, the physician or hospi tal (respectively) must incur a cost for the drug or biological.  G enerally, the a dministration  of drugs or biologicals covered by Medicare under the inc ident to benefit (1861(s)(2)(A) and (B)) will start and end while the patient is in the physicians office or the hospi tal outpatient department under the supervision of a physician. However, in some situations a hospital or office may purchase a  drug for a medically reasonable and necessary prolonged drug infusion, then begin th e drug infusion in the care setting using an external pump, send the patient home for a portion of the infusion duration, and have the patient return at th e end of the infusion period.  In this case, the drug or biological continues to be cove red under secti on 1861(s)(2)(A) and (B) of the Act and is billable to the MAC even though the entire administration of th e drug or biological did not occur in the physicians offi ce or the hospital outpatient depa rtment.  Also, the drug or biological continues to meet the r equirements for the incident to benefit as the physician or hospital incurred a cost for the drug or biological and the administration of the drug began in a physicians office or hospital incident to a physicians service.  For the administration of the drug, the phys ician supervision rules und er 42 CFR 410.26(b)(5) and 42 CFR 410.27 (a)(1)(iv) and CMS Publication 100-02, chapter 15 , section 50.3 apply only while the patient is present in the physicians office or hospital outpatient department.  CMS does not provide specific coding guidance; however, appropriate drug administration codes for this situation would desc ribe the services that are provided by the physician or hospital (for example, intravenous infusion, patient monitoring ) while the patient is in the office or the outpatient setting. Medicares payment for the administration of the drug or biolog ical billed to the MAC will also include payment for equipm ent used in furnishing the service.  Equipment, such as an external infusion pump used to be gin administration of the drug or biological that the patient takes home to complete th e infusion, is not separately billable as durable medical equipment for a drug or biol ogical paid under th e section 1861( s)(2)(A) and (B) incident to benefit.  The MAC may direct  use of a code described by CPT or an otherwise applicable HCPCS code for the drug adminis tration service.  If necessary, the MAC may direct use of a miscellaneous code for the drug a dministration if there is no  specified code that describes MLN Matters Number: SE1609 Relat ed Change Request Number: N/A   Page 3 of 3 the drug administration service that also accounts for the cost  of equipment that the patient takes home to complete the infu sion that they later return to the physician or hospital. Additional Information If you have questions, your MACs may have more information. Fin d their website at http://go.cms.gov/MAC-website-list . DOCUMENT HISTORY  Date of Change Description June 6, 2019 We revised this article to update the web links. A ll other information is unchanged. April 4, 2016 Initial article released.   Disclaimer This article was prepared as a service to the public and is not  intended to grant rights or impose obligations. This article m ay contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and othe r interpretive materials for a full and accurate statement of their contents. CPT only copyr ight 2015 American Medical Association.   Copyright  2018, the American Hospital Association, Chicago, I llinois. Reproduced with permission. 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