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Stay on Your Toes for Pharmaceutical Changes to Come

The drug revolution in APCs has just begun

CMS hasn't ironed out the details, but keep your chargemasters peeled for drug reimbursement in these areas:
Radiopharmaceuticals
Trela says to expect changes to the rules for administration of radiopharmaceuticals because CMS has added 20 new APCs for them. The agency has also dropped the separately payable threshold for these drugs from $150 to $50. "They're still looking at it," Trela says. "They don't feel like they've really got a handle on it yet."
Orphan drugs
For orphan drugs - medications that have only one, very specific use - you will receive varying payment, depending on which drug you administer. Ten will earn you 88 percent of their AWP, and two will earn 94 percent.
LOCM
If you're still puzzled by billing for low osmolar contrast media (LOCM), you're not alone. "There's no separate APC for it," Trela says, "and there are no requirements anymore to differentiate between high osmolar or low osmolar. It's bundled with the procedure, so there are no restrictions to limit payment." Previously, you needed to document a certain diagnosis if you wanted reimbursement. But now that it's bundled, you can earn LOCM payment for any diagnosis that's relevant and medically necessary.

- Published on 2004-02-09