Self-Administered Drug - WPS Medicare

Self-Administered Drug (SAD) Teleconference
October 24, 2012
Medicare Part B Coverage for Self-Administered Drugs
‣ Drugs, that are usually self-administered, are excluded from coverage
Even when administered on an outpatient emergency basis
Regardless of the route of administration
‣ Oral drugs, suppositories, topical medications
Considered to be usually self-administered by the patient
Covered if integral part of procedure
‣ Injectable drugs
Typically eligible for coverage under the “incident to” benefit
Determining What is a Self-Administered Drug
‣ Each Medicare contractor must make its own determination on each drug, and
Develop a process to review each drug for exclusion
Consider all administration routes in the determination for a drug
Publish a list of injectable drugs subject to the self-administered exclusion on website
‣ Made on a drug-by-drug basis
Not a beneficiary-by-beneficiary basis
Drugs excluded from coverage under this rule are always excluded from coverage
‣ “Usually” = more than 50% of the time for all Medicare beneficiaries who use the drug
Billing Self-Administered Drugs
‣ Not required to bill
Unless requested to do so by beneficiary or other insurance
‣ If billed, use
Revenue code 637
Appropriate HCPCS
HCPCS A9270 – may be used if no other appropriate HCPCS exist
Modifier GY
Charges non-covered
Updated 11/20/2012 1
http://www.wpsmedicare.com/

Drugs Treated as Hospital Outpatient Supplies
‣ Medicare pays for drugs that may be considered usually self-administered by the patient when such
drugs function as supplies
Drugs provided are an integral component of a procedure or are directly related to it
‣ Except for the applicable copayment, hospitals may not bill beneficiaries for these types of drugs
‣ Report coded and uncoded drugs with their charges under appropriate revenue code
Cost center under which the hospital accumulates the costs for the drugs
Appealing Self-Administered Drugs
‣ Beneficiaries may appeal the denial
Because it is a “benefit category” denial, an ABN is not required
‣ Providers may also appeal the denial
References
‣ CMS Internet-Only Manual (IOM)
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.2
Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 60.4.2
‣ WPS Medicare SAD listing and policy
http://wpsmedicare.com >> Appropriate Part A contract >> Policy >> Self-Administered Drug
Exclusion List (SAD List)
This program is presented for informational purposes only. Current Medicare regulations will always prevail.
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