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Topic: Examine reimbursement for refills

Ambulatory Surgery Reimbursement Update, December 16, 2008

Infusion pumps have reservoirs that hold medicine, which is dispensed around the clock for weeks or months at a time. Therefore, a healthcare provider has to refill the reservoirs at some point.

ASCs should bill for the drugs used to fill the pumps. It’s important to note that Medicare does not pay ASCs for these drugs unless they are payable under the OPPS.

Under the new payment system, Medicare will reimburse ASCs for drugs that have a status of K, indicating that they are not a pass-through drug, but they are eligible for separate payment, says Linda Van Horn, MBA, president and CEO of 21st Century Edge in Kansas City, MO.

Drugs commonly used in pumps that are eligible for separate payment include:

• Codes J0475 and J0476 (Baclofen)
• Code J0735 (Clonidine)
• Code J2278 (Ziconotide or Prialt)

Commonly used drugs that are not payable include morphine and Dilaudid (hydromorphone). Also, Medicare does not pay refill CPT codes 95990 or 95991 because it views them as nursing or physician codes for refilling and bundled into payment for the APC.

Consult the table of payable drugs, which Medicare updates quarterly. To view the quarterly updates, go to www.cms.hhs.gov/ASCPayment/ASCQuart. Most Medicare carriers have special rules for reporting compound drugs, so check with your local Medicare carrier for any specific rules, Van Horn says.

Editor’s note: This topic is from the December 2008 issue of Ambulatory Surgery Coding and Reimbursement Insider.

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