Last Modified: 9/28/2022
Location: FL, PR, USVI
Business: Part A
CMS provides instructions to contractors regarding Medicare payment for drugs and biologicals incident to a physician’s service. The instructions also provide the contractor with a process for understanding if an injectable drug is “usually” self-administered (to mean a drug you would normally take on your own) and therefore not covered by Medicare.
• The term “usually” means that the drug is self-administered more than 50% of the time for all Medicare beneficiaries who use the drug and are considered excluded from coverage.
Providers are not required to bill non-covered self-administered drugs unless requested by the beneficiary or secondary insurance. If a line item denial is required that holds the beneficiary liable for the non-covered self-administered pharmacy services, the outpatient claim should be submitted as follows:
• Revenue code 0637
• HCPCS code that describes the services rendered; or,
• Use A9270 (non-covered item or service) when there is no other appropriate code
• Modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit)
• Reason code 31324 will append to the line item when the GY modifier is present, and holds the beneficiary liable
• Reason code 31947 will apply to the line item when the GY modifier is not present, and holds the provider liable
• Advanced beneficiary notice (ABN) is not required
• Charges non-covered
• Do not submit the charges as covered
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.