RETIRED - Billing of Part B Drugs to DME MACs During COVID-19 Pandemic - Dispensing Amounts - JA DME

Joint DME MAC Article

Under current Medicare rules, for immunosuppressive drugs used after an organ transplant, oral anticancer drugs and intravenous immune globulin (IVIG), utilization requirements generally limit dispensing of drug amounts to a 30-day supply. With the recent COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), under their National Emergency authority, is allowing Medicare beneficiaries to obtain amounts of Part B drugs in excess of the current monthly (30 day) limitation. This change is effective for claims with dates of service on or after March 1, 2020.

In the event that a treating practitioner prescribes more than a monthly (30 day) amount, the CR modifier (CATASTROPHE/DISASTER RELATED) must be added to the HCPCS code billed. In addition, suppliers are instructed to enter "COVID-19" in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 498-PP of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

In the event of an audit, review contractors will identify these claims by the "COVID-19" entry and assess if the amount was reasonable and necessary, based on the nature of the particular drug, the patient's diagnosis, the extent and likely duration of disruptions to the drug supply chain during the COVID-19 national emergency, and other relevant factors.

Refer to the applicable Local Coverage Determinations and related Policy Articles for additional coverage, coding and documentation requirements.

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