Medicare Clarifies that Prohibition on Billing Beneficiaries for “Dropless” Surgery Continues

Date: October 12, 2019

The Centers for Medicare & Medicaid Services (CMS) clarified their previous stance that unless a drug has pass-through billing status, drugs administered in the facility (ASC or HOPD) will not be separately billable to beneficiaries since they remain included in the packaged facility payment as before.  This includes injected drugs as well as drugs patients purchase and bring to the facility for use there.

Evidently the issue arose because of confusion regarding a recent Change Request (CR) and accompanying CMS Transmittal that was issued to be effective on October 1, 2019.  Transmittal 4411 (link here) had a section titled “5. Clarification on the Guidance for Intraocular or Periocular Injections of Combinations of AntiInflammatory Drugs and Antibiotics”.  Some read this CR/Transmittal as now allowing beneficiaries to be billed for “dropless” eye surgery, since in addition to the title of the section, there was a sentence in this document as follows:

However, nothing in this CR is intended to preclude physicians or other professionals from discussing the potential benefits and drawbacks of dropless therapy with their patients and prescribing it if the patient so elects. 

We asked for clarification as did the AAO.  The responses from CMS stated that there was nothing in this Transmittal that changed the original guidance they published from September 2015, they were only clarifying that a discussion could take place but billing prohibitions remained unchanged.  You can link to that older guidance here).  It stated:

Although these drugs are a covered part of the ocular surgery, no separate payment will be made [and that according to] … the Medicare Claims Processing Manual, Chapter 30, section 40.3.6, physicians or facilities should not give Advance Beneficiary Notices (ABNs) to beneficiaries for either these drugs or for injection of these drugs because they are fully covered by Medicare. Physicians or facilities are not permitted to charge the patient an extra amount … for these injections or the drugs used in these injections because they are a covered part of the surgical procedure. Also, physicians or facilities cannot circumvent packaged payment in the HOPD or ASC for these drugs by instructing beneficiaries to purchase and bring these drugs to the facility for administration.

The current policy continues.  All drugs injected or used at the facility (except for separately payable “pass-through” drugs) are part of the payment to the facility.  Additionally, providers and facilities cannot use an ABN to shift responsibility onto the beneficiary, nor can they write a prescription to be purchased by the patient which are then brought to the facility for administration.

We are happy to assist groups and facilities with general claims issues and other coverage topics, which include proper code selection, chart reviews, and payer action questions.  We provide training on these and other subjects.  You can download our “App”, Corcoran 24/7 via one of the links below.

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