Revised: Billing Reminder - Immunosuppressive Drugs - Delivery to Inpatient Hospitals - JA DME

Joint DME MAC Publication

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.  The Centers for Medicare & Medicaid Services (CMS) recently revised the rules for early delivery of immunosuppressive drugs for use post-transplant. 

Effective for dates of service on or after April 3, 2019, the new rules now allow early delivery of the initial prescriptions of a beneficiary's immunosuppressive drugs to an alternate address, such as the transplant facility or alternative location where the beneficiary is temporarily staying, e.g., temporary housing, instead of delivering the drugs to the patient's home address. Note that this is an optional, not mandatory, process. If the supplier ships immunosuppressive drugs to an alternate address, all parties involved, including the beneficiary and the transplant facility, must agree to the use of this approach. Early and/or direct delivery to the transplant facility does not change the facility's responsibility to provide all immunosuppressive drugs required by the beneficiary for the duration of the beneficiary's inpatient stay. All other applicable Medicare and DME MAC billing requirements continue to apply.

Note that the following additional conditions also apply:

1. The supplier must not receive separate payment for immunosuppressive drugs prior to the date the beneficiary is discharged.
2. The supplier must not mail or otherwise dispense the drugs any earlier than two days before the anticipated date of the beneficiary's discharge. It is the supplier's responsibility to confirm the beneficiary's discharge date.
3. The supplier must not submit a claim for payment prior to the beneficiary's actual date of discharge.
4. The immunosuppressive drug must be medically necessary on the date of discharge, i.e., there is a valid prescription for an immunosuppressive drug that is reasonable and necessary and is clinically required to be available no later than the date of discharge for home use.
5. The supplier must not claim payment for additional costs that the supplier incurs in ensuring that the immunosuppressive medications are delivered to the alternative location. The supplier also must not bill the beneficiary for redelivery if it is necessary.

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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