Post

By Kim Turner, RN, Clinical Consultant

CMS has recently published guidelines for billing of Part B Drugs to DME MACs During COVID-19 Pandemic. During the pandemic, the beneficiary will be allowed to obtain amounts of Part B drugs in excess of the current monthly (30 day) limitations.  

Under the current Medicare coverage and payment requirements for immunosuppressive drugs used after an organ transplant, oral anticancer drugs and intravenous immune globulin (IVIG), utilization requirements generally limit dispensing of drug amounts to a 30-day supply. With the recent COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), under their National Emergency authority, is allowing Medicare beneficiaries to obtain amounts of Part B drugs in excess of the current monthly (30 day) limitation.

This change is effective for claims with dates of service on or after March 1, 2020.

If the beneficiary’s treating practitioner prescribes more than the monthly (30 day) amount, the CR modifier (CATASTROPHE/DISASTER RELATED) must be added to the HCPCS code billed.

In addition, suppliers are instructed to enter:  

• "COVID-19" in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or,
• “COVID-19” in Field 498-PP of the National Council for Prescription Drug Program (NCPDP) format and,   
• These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

To ensure compliance if the claim is audited by the review contractors, the audit contractors will identify these claims by the "COVID-19" entry. Based on the nature of the drug ordered, the beneficiary’s diagnosis, the extent and likely duration of disruptions to the drug supply chain during the COVID-19 national emergency, and other relevant factors, the auditor will then determine if the amount billed was reasonable and necessary.

Please refer to the applicable Local Coverage Determinations and related Policy Articles for additional coverage, coding and documentation requirements.