CMS Releases Clarification on Billing for Prolonged Infusion Services

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  • May 3, 2016

MLN Matters® Number: SE1609

Medicare Policy Clarified for Prolonged Drug and Biological Infusions Started Incident to a Physician’s Service Using an External Pump  

On Friday, April 29, CMS released MLN Matters® Number SE1609, which they describe as a clarification. In fact, the clarification outlined in this MLN Matters Special Edition article fundamentally changes our understanding for billing external infusion pumps that are initiated in the HOPD or physician office and sent home with the patient for the remainder of the CIV infusion of the drug or biological.

In the past, the rules for billing for these services and the drugs provided via the ambulatory infusion pump have been a bit confusing as the direction provided from the DME MAC and the Part B MAC were often at odds.

The CMS MLN Matters article was published in response to the confusion between the DME and Part B MACs and their request for guidance.

SE1609 begins by describing the service when a prolonged infusion is started in the HOPD or physician office using an external infusion pump which the patient is sent home with to continue the infusion and then the patient returns at the end of the infusion period.

CMS states that under that scenario the drug or biological, the administration, and the external infusion pump is to be billed to the MAC. However, CMS goes on to say that because the prolonged drug and biological infusions started incident to a physician’s service using an external pump should be treated as an incident to service, it cannot be billed on suppliers’ claims to DME MACs.

Furthermore, in the last paragraph on page 2 of the article, CMS explains that the pump itself is not separately billable to the MAC as Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service.

CMS states that the MAC may direct use of a miscellaneous code for the drug administration if no specified CPT code describes the drug administration and also accounts for the cost of equipment the patient takes home to complete the infusion that they later return to the physician or hospital.

Here is an excerpt from the MLN Matters article:

Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit. The MAC may direct use of a code described by CPT or an otherwise applicable HCPCS code for the drug administration service. If necessary, the MAC may direct use of a miscellaneous code for the drug administration if there is no specified code that describes the drug administration service that also accounts for the cost of equipment that the patient takes home to complete the infusion that they later return to the physician or hospital. 

Practices should be looking for an article from their Part B MAC with specific instructions for billing these services.