Famotidine

ksb0211

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Hello, all!
I have tried to find the correct answer for this but can't seem to find recent information that I feel was "concrete." I'm hoping someone out there can assist me. We recently changed our drug cabinet so we are now trying to fix any issues.

Medication: Pepcid/Famotidine S0028

Medicare does not cover this medication and we have not obtained any ABNs. Is this code billable when given at the same time as other medications (chemo)? I have seen documentation that indicates J3490 (NOC) should be billed but didn't feel the information was recent enough nor could I confirm anywhere else that this was accurate.

If you do not bill the patient for this medication and it is written off, do you bill an admin charge for this or would it be included with the admin of other meds?

Thank you for all your time with this as this is a new situation for me.
 

SharonCollachi

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Since there is no J code for it, you can try billing it with an unlisted code.

I wouldn't get an ABN for it, it seems rather... petty? Not sure that's quite the right word to convey what I'm thinking. My mom went thru chemo about a year ago, then surgery, was declared clear and good, then her cancer came back, and she just finished another round of chemo plus radiation this time. She lives with me and I took her to all of her appointments. If her cancer center had said, "we want to give you some pepcid to help protect your stomach from excess acid, but Medicare won't pay for it, so we'd like you to sign this and you will pay for it," I would have marched into the managers office, plunked down $10, and said, "here, this will cover 6 single-dose vials, if she doesn't use all the doses, use it to pay for someone else, and don't ask her to sign another ABN, you let ME know if there is a problem." A 2ml single dose vial of 20mg is $1.66 from my regular medical supplier.

An ABN for one dollar and sixty-six cents... that's what I mean by it sounds "petty". As someone who has spent quite a bit of money (and she is double-covered, but there is travel, and hotels, and time off work, and meals away, and certain supplies for her ostomy that Medicare won't cover, even with help from the American Cancer Society), let alone time and energy, both emotional and physical, I would probably lose my shit at $1.66.

I'm not angry, and I hope this doesn't come off this way. It's just that being on the other side, I wanted to try to convey how it feels.
 

ksb0211

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I agree with you, Sharon regarding the petty amount that would be billed.
Honestly, we were never going to bill the patients which is why we haven't had any ABNs signed and if it sounded like that in my post that was my error. We were simply trying to figure out if the admin was a covered charge and if so, would THAT be covered by Medicare to assist with the cost of the med to the provider's office or if it all was considered bundled. Our provider is fully aware that these chemo meds are already expensive and we always do our best to make things as easy as possible for our patients, both medically and financially. :)
Thanks for your insight, though!
 

thomas7331

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Are you sure that Medicare does not cover this drug if administered through infusion? Medicare does not cover it if self-administered, but if it is given IV, I'm not aware that this is the case. The fact that Medicare does not recognize the HCPCS code S0028 does not mean that they do not cover the drug that this code represents. I agree that J3490 would be the appropriate code to submit if there is no other HCPCS code.

And yes, you should bill an administration charge, e.g. a subsequent or concurrent code, if supported in the documentation of the encounter. Those codes are not bundled. It's not appropriate to code incorrectly or omit charges that are a part of the service during the encounter based solely on the expectation of a denial or write-off - your coding should always accurate reflect the services.

In addition, I'd just note that it's actually a non-compliant practice to offer Medicare patients goods or services for free because that can be considered giving an inducement to the patient. Granted in a situation like this where the cost is relatively low it is unlikely to incur a sanction, but all the same, it's not a legal practice and should be avoided.
 
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SharonCollachi

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In addition, I'd just note that it's actually a non-compliant practice to offer Medicare patients goods or services for free because that can be considered giving an inducement to the patient. Granted in a situation like this where the cost is relatively low it is unlikely to incur a sanction, but all the same, it's not a legal practice and should be avoided.

I absolutely agree with you there. However, when the cost to bill it is more than the reimbursement, I would argue my case (I've never had to, and I may be speaking out of turn here). I also don't send multiple statements to Medicare patients or ANY patient when the bill is under $5; I send it once, call it good, and be on my way.
 

trarut

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::snipped::

Medication: Pepcid/Famotidine S0028

Medicare does not cover this medication and we have not obtained any ABNs. Is this code billable when given at the same time as other medications (chemo)? I have seen documentation that indicates J3490 (NOC) should be billed but didn't feel the information was recent enough nor could I confirm anywhere else that this was accurate.

If you do not bill the patient for this medication and it is written off, do you bill an admin charge for this or would it be included with the admin of other meds?

::snipped::

ksb0211,
The oncology group I work for does not bill for S0028 or the administration for any payer. The decision was made that (1) it's not worth the work of billing for the minimal reimbursement from the few plans that will recognize the S code, (2) definitely not worth having a high dollar chemo claim held up for using an unlisted drug code and (3) we don't bill the admin code for reasons related to #1 and #2 ;) The admin was usually denied up front because there wasn't a 1:1 match with a billed drug OR it was paid then recouped during a post-payment audit for the same reason. Ultimately, we spend far more than we'll ever be paid by processing the charge, billing it, doing the claim follow-up, etc so we just don't.

Hope this helps.
Tracy
 

rachaelwilleford

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Famotidine is listed on Medicare's NOC ASP file. Per CMS:
Note 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code
to use in reporting these drugs to Medicare.

We use J3490 for Medicare (we are Novitas). For commercial, S0028 is usually appropriate.
 
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