Article Detail - JD DME

Article retired due to content incorporation into the applicable Local Coverage Determination or related Policy Article.

Original Effective Date: 07/15/2003
Revision Effective Date: 11/01/2013

The DMERCs make payment for immunosuppressive drugs for beneficiaries who receive a covered organ transplant and who meet all other Medicare coverage criteria for immunosuppressive drugs once the patient has returned to their home. Suppliers are required to complete a DMERC Information Form (DIF) prior to submission of claims for immunosuppressive drugs for use in the home.

For a pharmacy that delivers by shipment, it is reasonable to expect that it may need to ship medication to the patient up to 2 days prior to the date the patient will be discharged so that the drugs will arrive at the patient's home when they return.

Under normal circumstances, the date of service listed on the claim must be the date the supplier actually delivered or shipped the item. However, under the circumstance described above, the DMERC claim processing systems will, appropriately, reject the claim with a date of service listed as being prior to the patient's date of discharge, because the hospital remains responsible for the provision of immunosuppressive drugs while the beneficiary is still an inpatient.

Therefore, for a pharmacy that delivers medication by shipment, the pharmacy may enter the date of discharge as both the initial date on the DIF form and as the date of service on the first claim it submits for the beneficiary after the beneficiary is discharged. Note that this is an optional, not mandatory, process. If the pharmacy does not want to ship the immunosuppressive drugs prior to the beneficiary's date of discharge from the hospital, they may wait for the beneficiary to be discharged before doing so, and follow all applicable Medicare and DMERC rules for immunosuppressive drug billing (e.g., the date of service will be the date of delivery/shipping).

Note that the following conditions apply:

1. The facility remains responsible for all immunosuppressive drugs required by the beneficiary for the duration of the beneficiary's inpatient stay. The pharmacy must not receive separate payment for immunosuppressive drugs prior to the date the beneficiary is discharged.
2. The pharmacy must not ship or otherwise dispense the drugs any earlier than 2 days before the patient is discharged. It is the pharmacy's responsibility to confirm the patient's discharge date if they choose to take advantage of this option.
3. The pharmacy must not submit a claim for payment prior to the beneficiary's date of discharge.
4. The beneficiary's discharge must be to a qualified place of service (e.g., home, custodial facility, skilled nursing facility – if not during Medicare Part A covered stay), but not to a facility that does not qualify as the beneficiary's home (e.g., inpatient hospital or skilled nursing facility – during Medicare Part A covered portion of stay).