Health Information Management

Q&A: Why did the MAC return a claim for a covered drug administration?

APCs Insider, October 18, 2013

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Q: Our MAC has recently updated the self-administered drug (SAD) listing and removed Orencia® and Simponi® Aria from the list. These are now considered covered services. We reported the drug administration service and the HCPCS code for the drug, but the claim was returned. We checked the HCPCS code, units, and the drug administration service and all were coded/reported appropriately. Why would the MAC return the claim?

A: Your MAC may not have changed the flag in its claims processing system. On September 30, CMS determined that abatacept (J0129 Orencia) and golimumab (J3590 Simponi Aria) are separate drugs and not usually self-administered. Therefore, they are now considered covered drugs as long as all the conditions for coverage are met, the use is a medically necessary infusion, and incident to a physician’s service.

Beginning December 1, 2013, you may need to append modifier -KX (requirements specified in the medical policy have been met) to the HCPCS code for the drug and drug administration service to indicate that it was medically necessary to use the infusion formulation for the specific administration of either drug. The drug administration code and the drug HCPCS codes must be reported on adjacent lines on the same claim.

The medical record must clearly document why this specific form of the drug and mode of administration was medically necessary. If the conditions for coverage have not been met, then report the appropriate modifier –GA (waiver of liability statement on file), -GZ (item or service expected to be denied as not reasonable and necessary), or -GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit) n both the drug and the administration code. If a modifier is not reported on both the drug and the administration line item, the claim will be returned as unprocessable.

Noridian has an article explaining these requirements for its jurisdiction. Providers should check their individual MAC to see if the modifier reporting is a requirement.

In addition, Noridian’s article has the following language: “Providers are reminded that convenience for the beneficiary or for the provider does not meet medical necessity under Medicare. Therefore concern for a patient’s financial liability or that a patient’s compliance with the medication regimen will suffer if the drug is not provided incident to a physician’s service, does not justify medical necessity.”

Complete and appropriate documentation will be required to support the medical necessity.

For more information, see Medicare Benefit Policy Manual, Pub 100-02, Chapter 15, Section 50.1.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, Fl., answered this question.



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