Wiki PLEASE HELP 67028 with drugs

[cherylbr]

When billing for both (ASC)- Facility & provider, is this the appropriate way to bill each scenario and how does Medicare allow for payment on the below scenario:

Scenario 1:

Provider claim in (ASC)-outpatient facility setting: 67028
(provider supplying drug) J0178

Facility(ASC) - claim in outpatient facility setting: 67028
(provider supplied & billed drug)


Scenario 2:

Provider claim in (ASC) - outpatient facility setting: 67028
(drug supplied & billed by (ASC) - facility)

Facility (ASC) - claim in outpatient facility setting: 67028
(Facility (ASC) - supplied & billed drug) J0178


I'm not sure if the drugs are only reimbursed if provided by the facility (ASC) when services are performed there or/if they will reimburse the provider for supplying the drug for the procedure at the (ASC) facility.

 

[thomas7331]

Scenario 2 is the only correct way to bill. I don't know of any payer that will reimburse a drug to a professional provider if the drug was administered in a facility. Drugs, like any supplies or any other material costs involved in treating a patient in a facility, are inclusive to the contract rates that are paid to the facility and would not normally be separately payable to outside entities. But I'm always somewhat amazed that this questions comes up so frequently because in addition to reimbursement issues, it is likely against hospital policy and non-compliant for an outside provider to bring in drugs to administer to patient within that facility. Hospitals are responsible for the drugs and any potential any adverse effect or medication errors that patients have while in the facility, and those drugs needs to be tracked by the hospital's internal pharmacy policies and procedures. Bringing in outside medications that aren't tracked is a serious potential patient safety and liability concern and something that just shouldn't happen, in my opinion.

 

[cherylbr]

Thomas

Thank you very much on your response. I did forget to mention in my initial post that this would be done in an ASC facility. I believe I read somewhere that even if the drugs were provided by the facility, an (ASC), then they would be inclusive to the procedure 67028 and would not be separately reimbursed. Does that sound correct?...... or are the drugs reimbursable?

 

[thomas7331]

That would depend on the facility's contract with the payers, and on the particular payer's reimbursement policy. For Medicare, and payers that follow Medicare OPPS reimbursement, drug charges are often inclusive to the case rates for procedures, but not always - it will depend both on the drug and the procedure. Basic injections and low cost procedures, such as 67028, are not usually paid at comprehensive rates, in which case there will be a separate allowance for the drug charges.