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Policy No:  107

Originally Created: 03/01/2016

Section: Facility

Last Reviewed: 05/01/2019

Last Revised: 05/01/2019

Approved: 05/02/2019

Effective:  06/01/2019

The policy applies to all physicians, other health care professionals, hospitals and other facilities.

Definitions

Topical Multi-Dose Drugs and Biologicals

Drugs and biologicals that are administered on the skin (topical) from a tube/container containing multiple doses and is not intended for a single use.  This includes, but is not limited to, ointments, creams, drops and sprays.

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.

Multi-Use containers/tubes are intended for multiple applications for a single patient. Topical drugs and biologicals from a multi-use container that are discarded, wasted or not administered are not eligible for reimbursement.

Additional documentation in the patient's record must include name of drug, date administered, actual dose administered to the patient, actual amount wasted or discarded and total amount the package/container is labeled to contain.

References

Report on Medicare Compliance: Units of Service are in Billing Limelight with Inhalation Treatment, Drug Audits. Atlantic Information Services, Inc.  2014

Medicare Claims Processing Manual. Chapter 17 - Drugs and Biologicals

Verhovshek, G. John, MA, CPC. Drug Waste = Money. AAPC. August 20, 2010

Cross References

Reimbursement of Medications for Facilities

Reimbursement of Multi-Dose Inhaled Medications for Facilities

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.