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Policy No:  102

Originally Created: 03/01/2015

Section: Facility

Last Reviewed: 05/01/2019

Last Revised:  07/01/2018

Approved: 05/02/2019

Effective:  07/01/2019

The policy applies to providers and facilities.

Definitions

The Medication Administration Record (MAR or eMAR for electronic version)

The report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional. 

Route of Administration

A path by which a drug is given to the patient.  Examples are, but are not limited to, oral, sublingual, rectal, topical, nasal, intramuscular, subcutaneous, intravenous, inhalation and transdermal.

National Drug Code (NDC) 

A unique 11-digit, 3-segment number assigned to each medication listed under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. The number identifies the labeler or vendor, product, and trade package size.

Policy Statement

Our health plan requires the NDC number, NDC units, and units of measurement to be placed on professional and/or outpatient facility claims to determine the standard reimbursement amounts for therapeutic and diagnostic drugs and biological products reimbursed under medical coverage.

Medications and medication waste must be recorded in the appropriate patient clinical record to be eligible for reimbursement. Medications not documented in an appropriate patient clinical record are not reimbursable. Reimbursement for medications that are separately reimbursable, regardless of route of administration, is governed by this policy. Note that medications are not separately reimbursable in certain settings, including but not limited to ambulatory surgical centers.

The appropriate patient clinical record for a patient admitted as an inpatient is the MAR or eMAR. Notwithstanding the above, drugs that are administered as part of a procedure are not separately reimbursable.

Anesthesia medications documented in an  anesthesia record which denotes the anesthesia care given, the drugs and fluids administered and the patient's responses to the anesthesia care are eligible for reimbursement. Medications administered in the emergency department which are documented in the patient clinical emergency department record are eligible for reimbursement. In order for anesthesia or emergency department medications to be eligible for reimbursement, all of the following must be documented in the anesthesia or emergency department record: name of the medication, route, amounts dispensed, amounts wasted, concentrations, date and time of administration.

References

Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual. Chapter 17, Drugs and Biologicals. Section 40

Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual. Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS). Section 10.4   (Note: In the absence of inpatient guidelines, outpatient guidance is followed)

Cross References

Reimbursement of Intravenous (IV) Solutions, Premixed IV Medications and Total Parenteral Nutrition (TPN) for Facilities

Discarded Drugs and Biologicals

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.