What is a pass-through payment for Medicare?
Medicare makes “pass-through” payments under Medicare Part B when hospital outpatient departments use certain new, high-cost drugs. These temporary payments are in addition to Medicare’s payments for the procedures using the drugs.
What is CMS payment limit?
The payment limit is 100 percent of the lesser of the lowest brand or median generic WAC. At the contractors’ discretion, contractors may contact CMS to obtain payment limits for Page 3 drugs not included in the quarterly ASP or NOC files or otherwise made available by CMS on the CMS Web site.
How do I bill Medicare for compounded drugs?
When billing for a compounded drug, the information must be put into item 19 of the paper claim form or the electronic equivalent. Providers should indicate the drug is compounded and include the drug name and total dosage given for each drug.
What does pass through mean?
(pass through something) to go to a place for only a short period of time before continuing a journey.
How does pass through status work?
Pass-through status is awarded by the US Department of Health and Human Services on a case-by-case basis for newly FDA-approved drug and device products. The initial payment for the new device or drug is established based on a complex formula, which establishes a floor price above which the product must be priced.
What is Medicare condition code 47?
Occurrence code 47 — indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date.
WHO calculates ASP?
For each billing code, CMS calculates a weighted average sales price using the Average Sales Price (ASP) data submitted by manufacturers. Manufacturers submit ASP data at the 11-digit National Drug Code (NDC) level.
How are Medicare Part B drugs reimbursed?
for Part B-covered prescription drugs that you get in a doctor’s office or pharmacy. In a hospital outpatient setting, you pay a copayment of 20%. If your hospital is participating in a certain outpatient drug discount program (called “340B”), your copayment will be 20% of the lower price, with some exceptions.
How do you bill for unclassified drugs?
After the year, if a drug or biological does not have an established or valid HCPCS code, then it should be billed with a NOC code. NOC codes are for “Unclassified drugs” or “Not Otherwise Classified” drugs (J3490) and biologics (J3590).