External Pump or Take Home Infusion Medicare Billing
Medicare recently published MLN Matters SE1609, Medicare Policy Clarified for Prolonged Drug and Biological Infusions Started Incident to a Physician’s Service Using an External Pump, and addresses this specific scenario. The patient is treated in the hospital outpatient department (HOPD) or physician?s office, requiring the providing entity to purchase the drug for the infusion. The infusion is initiated in the office/HOPD utilizing an external pump, with the patient leaving and then returning at the end of the prolonged infusion period. Medicare pays for medically necessary drugs and biologicals that are not usually self-administered when furnished incident to a professional service, under the sections 1862(s)(2)(A) and (B) of the Social Security Act. While the Center of Medicare and Medicaid Services does not provide specific guidance to providers regarding coding, they note that the drug administration services would include the costs of the equipment required to furnish the service. This equipment is not separately billable as Durable Medical Equipment, because the service is provided and paid under the incident to benefit. The service is billed to the Medicare Administrative Contractors by the providing physician office or HOPD, based on the information in SE1609. The ?Medicare Administrative Contractors” may direct use of a code described by CPT or an otherwise applicable HCPCS code for the drug administration service. If necessary, the Medicare Administrative Contractors 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? for the duration of the infusion.
Each provider should be sure that the cost of utilizing the pump is included in the charge for the prolonged drug administration service to insure that accurate cost information is reported to the CMS.