Incident-to Rx Billing Clarified

In what situations a pharmacy can bill when it’s dispensing certain drugs has been clarified in Transmittal 2312, posted by the Centers for Medicare & Medicaid Services (CMS). The transmittal also cautions physicians on not billing what the pharmacy has dispensed.

This transmittal rescinds Transmittal 2271, dated Aug. 5, to change the implementation date to Jan. 1, 2012.

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Under the guidelines, pharmacies may bill Medicare Part B for certain classes of drugs including immunosuppressive, oral anti-emetic, and oral anti-cancer. They may also bill for drugs self-administered through any piece of durable medical equipment (DME).

Pharmacies and providers cannot bill Part B  contractors for drugs dispensed directly to a patient for administration incident-to a physician service, such as refilling an implanted drug pump. And pharmacies can’t bill their durable medical equipment Medicare administrative contractor (DME MAC) for drugs furnished to a physician for a Medicare patient. The only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy.

In the unusual case where the pharmacy dispenses a drug to be administered through an implanted DME by someone other than the physician, the patient’s DME MAC or Part A/B MAC will reimburse for the drugs.

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