RETIRED - Billing Reminder - Immunosuppressive Drugs - Delivery to Inpatient Hospitals - JA DME

Joint DME MAC Article

The Durable Medicare Equipment Medicare Administrative Contractors (DME MAC) have jurisdiction for the Fee-For-Service Medicare program's coverage, coding and reimbursement for immunosuppressive drugs following transplant.  It has come to our attention that a common practice among pharmacies supplying immunosuppressive drugs is delivery to the patient while in an inpatient stay, often shortly prior to discharge, for use at home following discharge.  Billing of these claims to the DME MACs is improper and violates Medicare rules.  This article reviews the correct billing jurisdiction for immunosuppressive drugs provided post-transplant and includes an update to the Centers for Medicare & Medicaid Services (CMS) rules for delivery of immunosuppressive drugs.

The following summarizes the rules regarding immunosuppressive drug jurisdiction and delivery:

1. Pharmacies shipping or providing immunosuppressive drugs to an inpatient, post-transplant Medicare beneficiary for later use at home is improper.  Immunosuppressive drugs provided in this manner must not be billed to the DME MACs.
2. Medications necessary to facilitate discharge for use at home (or enroute to home) may be provided by the hospital.  Claims for this limited supply of drugs may be billed to the appropriate DME MAC (see Medicare Claim Processing Manual (Internet-only manual 100-04), Chapter 17, §90.4 below).
3. Pharmacies may ship or provide immunosuppressive drugs up to two (2) days prior to discharge; however, the medications must be shipped to the beneficiary's home or a place of service that qualifies as home, in order to be reimbursed by the DME MACs.

Background

Medicare rules stipulate that in order to prevent cost-shifting from one part of the Medicare program to another, drugs provided during an inpatient stay must be billed to the A/B MAC, specifically Part A.  Although there has been concern expressed by some transplant centers about a post-transplant patient being discharged to home and a potential "gap" in drug availability during travel to home, CMS makes allowances for this in the Medicare Benefit Policy Manual (Internet-only manual 100-02), Chapter 1, Section 30.5, which states:

30.5 - Drugs for Use Outside the Hospital

Drugs and biologicals furnished by a hospital to an inpatient for use outside the hospital are, in general, not covered as inpatient hospital services. However, if the drug or biological is deemed medically necessary to permit or facilitate the patient's departure from the hospital, and a limited supply is required until the patient can obtain a continuing supply, the limited supply of the drug or biological is covered as an inpatient hospital service. [Emphasis Added]

CMS instructs hospitals billing for this limited supply of drugs to bill these claims to the DME MAC, as instructed in Medicare Claim Processing Manual (Internet-only manual 100-04), Chapter 17, §90.4 which states, in pertinent part:

90.4 - Hospital Billing For Take-Home Drugs

All hospitals, including critical access hospitals (CAHs), bill the appropriate DME MAC for take-home supplies of oral anti-cancer drugs, oral anti-emetic drugs and multi-day supplies of immunosuppressive drugs, as well as the associated supplying fees. All inhalation drugs and the associated dispensing fees are also billed to the DME MAC.

Claims for these take-home drugs are billed on the NCPDP, a HIPAA-compliant telecommunication format specifically designed for drug billing. All entities billing on the NCPDP use the NDC for the particular drug being billed, and list units as multiples of the quantity represented by the NDC.  Supplying fees and dispensing fees must be billed on the same claim as the drug.

Because the Medicare program recognizes the critical nature of post-transplant care and avoiding any interruptions in a beneficiary's post-transplant immunosuppressive drug regimen, a recent change in program instructions was issued, effective March 9, 2018.  As noted in the Medicare Learning Network Matters^® article (MM 10370), CMS now allows immunosuppressive drugs to be delivered to the beneficiary's home (or a place of service that qualifies as home) up to two (2) days prior to discharge from an inpatient facility.  This article also re-emphasizes that immunosuppressive drugs may not be delivered to the beneficiary at the inpatient facility, even if the medications are for use following discharge to home.

Refer to the Immunosuppressive Drugs Local Coverage Determination (LCD) (L33824), related Policy Article (A52474) and Standard Documentation Requirements Policy Article (A55426) for additional coverage, coding and documentation requirements.

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