星空入口

Coding Corner: Drowning in Drug Payment Rules?

Stay above water with this APC drug guide

The oodles of changes surrounding outpatient drug payment can send your coding for a loop - especially when you're figuring out when to report medications separately from the procedural APC. Take this tour through the new regulations and find out how they affect your drug reimbursement.
Pass Up Expired Pass-Through Drugs
CMS has gone back through its files on pass-through items - all the way from Dec. 31, 2002 - and turned that status around. So you no longer earn the extra pass-through reimbursement for these "specified covered outpatient drugs." But now that they've assigned each item its own HCPCS code and ambulatory payment classification (APC) group, you can bill them separately from the procedure, says Patricia Trela, RHIA, consultant for Deloitte & Touche in Boston.
And though you won't be earning the pass-through payment you once could have earned, you can now separately bill more drugs than ever before - complete with an individual code and APC group for each. The $150 threshold for separately payable drugs dropped this year to $50, opening up separate payment for a host of drugs formerly wrapped into procedures' APCs. "Obviously, there's more drugs that you're going to need to put codes in for, and you will receive payment if you do that," Trela says.
Pass-through drugs also take another hit: They won't count toward the total for your outlier payments - and neither will brachytherapy drugs - so you will probably have fewer patients qualify as outliers overall.
Seek the Source, Get Your Check
Drugs you can bill separately - ones whose costs exceed $50 - fall into three categories, and the medication's category determines how much you'll get paid for it. "Hospitals are going to have to watch this," Trela says. Reim-bursement for all drugs only covers a percentage of the medication's cost, but that percentage isn't always the same.
Sole-source drugs - These medications are "brand drugs that are still under patent protection," says Diane Jepsky, RN, MHA, LNC, vice president of coding and compliance at CodeCorrect in Yakima, Wash. They have no generic equivalent. These drugs tend to be more expensive because the manufacturer is still paying off the costs of creating the drug, such as clinical trials and initial marketing expenses, Jepsky says. For sole- source drugs, you'll earn from 88 percent to 95 percent of the average wholesale price (AWP). 

Innovator multiple-source drugs - When the patent on sole-source drugs expires, and they become open to companies creating generic alternatives, these drugs are called innovator drugs. "In order to be in the innovator category, they  have had to be a sole-source drug," [...]

- Published on 2004-02-09