Patient/Manufacturer Supplied Drug identification on claims

Stephanie.ellis@uchicagomedicine.orgStephanie.ellis@uchicagomedicine.org
in GENERAL

Does anyone have CMS guidance regarding the designation of patient provided/supplied drugs on claims: Revenue Code, HCPC Code and Qty?

Comments

  • HeatherDuboisHeatherDubois

    Hello- We don't allow patient supplied meds, but for white bagged meds, we use the same rev code (usually 0636, same HCPC, same qty), but alternate the charge to $0.10 and move it to the non-covered column of the claim.

    CMS has guidance that makes anything under $1.10 a token charge, but we found they sometimes pay on $1.10, so switched to $0.10.

    Aetna requires a penny, so you may need logic for them too.

  • dwilliamsrsidwilliamsrsi

    The first question is - what type of drug is being provided by the patient? Is it an injectable drug that they are bringing with them for administration at the facility? Or is the patient bringing their own self-administered drugs to the facility so they don't have to pay for them again? If you have an edit for administration that is looking for a specific revenue code for the drug, report the drug under that revenue code (e.g., 636) with a nominal charge, which CMS defines as $1.00 or less. This allows the HCPCs code to resolve the edit, but CMS will not process the line item for payment. I would be careful reporting this as non-covered since if a drug is non-covered, so is the administration of the drug. (CMS notes this in the manual). If the drugs are oral and just the patient providing because they have already purchased or it is non-formulary for the facility, if you have to report these, use revenue code 0637 which is specific for self administered drugs, and charge a nominal fee in the non-covered column. However, be very careful in reporting in this last scenario - CMS states that to report a charge on a claim, the facility/provider must have incur a cost for the item. In this case, the facility incurred no cost for the self-administered drugs and there really isn't a reason (e.g., edit) from a claims processing perspective to report the drug(s). The information is in the CMS Provider Reimbursement Manual, CMS Benefit Policy Manual, Chapter 15, section 50.2.C)

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