Article - Billing and Coding: Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents (A53049)

Services Not Separately ReportableIf performed to facilitate an infusion or injection of a drug or biological, the following are included and are not reported separately:Use of local anesthesiaIV startAccess to indwelling IV, subcutaneous catheter or portFlush at conclusion of infusionStandard tubing, syringes and suppliesPreparation of chemotherapy agent(s)Biosimilar ModifiersEffective on April 1, 2018, providers and suppliers will no longer be required to report modifiers with HCPCS codes for biosimilars (reference the CMS Transmittal 3966, CR 10454).Compounded DrugsCompounded drugs are drugs not reconstituted as labeled in order to create a combination of drugs or vary the concentration/volume. As such, compounded medications do not have a National Drug Code (NDC) number, an average sales price (ASP) or an average wholesale price (AWP). Compounded drugs are contractor priced on invoice.Compounded medications created by a pharmacist in accordance with the Federal Food, Drug and Cosmetic Act may be covered under Medicare. A compounded drug is defined as a combination of drugs mixed by a pharmacist. This definition does not include a simple reconstitution of a drug as directed by the package insert. Compounded drugs that are self-administered are not a covered Medicare service.Coding Guidance:Compounded drugs should be reported with HCPCS code J7999 on a single claim line.Place quantity = 1 on the line billed for J7999.Enter the name, total dose (in mg or mcg) of each drug of the refill, and invoice amount in Box 19 of the CMS 1500 or the appropriate comment loop of electronic claims.Covered compounded single or combination drugs should be billed on a single detail line.Do not list the drug separately from the dosage, such as morphine bupivacaine baclofen sufentanil 20mg 6mg 4mcg 5mcg. This format will be denied.List each drug with the applicable dosing amount, for example morphine 20mg, bupivacaine 6 mg, baclofen 4 mcg, sufentanil 5 mcg.The ICD-10-CM code used on each detailed line must represent the condition treated by the drug(s) billed on that detail line.Drug doses used in narrative description must be in mgs or mcgs only. Do not report gs.Use of Infusion PumpsMedicare will consider infusion pumps and associated services medically reasonable and necessary for the conditions listed in the Medicare National Coverage Determination Manual Pub.100-03, Chapter 1, Section, 280.14.The use of compounded drugs has been especially prevalent in the filling of infusion pumps. The following methods are appropriate when billing for drugs used in infusion pumps:When submitting a claim for compounded drug(s) for a single agent or a combination of agents, providers must use HCPCS code J7999. Even though the compound is similar to or includes a drug with a specific HCPCS code, providers must use HCPCS code J7999, Compounded drug, not otherwise classified, for reimbursement of the compounded drug.The KD modifier must be appended to indicate the drug will be administered through Durable Medical Equipment (DME) such as an infusion pump.When a non-compounded drug is used (a true off the shelf product without compounding), the specific HCPCS code for the drug may be used.Note:Compounded drugs and/or combination drugs used in infusion pumps should be reported with HCPCS code J7999 andappended with modifier KD to indicate the drugs were infused through DME.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.