Clinical Coverage Topics
- When a medication is ordered and mixed, but it is not administered to the patient due to a change in patient status or a no-show by the patient for that day’s visit, can the hospital bill for the drug?
- What HCPCS code should be used if one can not be found for the medication that is being administered?
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No, payment cannot be made by the Medicare program in this situation. Administration of the drug is required before payment can be made.
Date Posted: 09/15/2005, Date Reviewed/Revised: 01/10/2008
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In the situation where there is no code to accurately describe the medication as in the case with a new drug, the provider should use the HCPCS J3490, "Unclassified Drugs". The code should be reported along with documentation identifying the drug, dosage, and route of administration.
Date Posted: 09/15/2005, Date Reviewed/Revised: 01/10/2008
For more information on the billing of medications and units please refer to the following links:
- Transmittal 968, Change Request 5028: Chemotherapy Administration and Nonchemotherapy Injection and Infusion Coding and Payment Policy - Update to Pub. 100-04 Medicare Claims Processing Manual
- Medlearn Matters: Payment for Chemotherapy Administration Services, Non-Chemotherapy Drug Infusion and Drug Injection Services
- Program Transmittal AB –02-075: Payment Limit for Drugs and Biologicals
- CMS Pub 100-4 Medicare Claims Processing, Chapter 17: Drugs and Biologicals
- CMS Pub 100-04 Medicare Claims Processing, Transmittal 902, Change Request 4388: Hospital Outpatient Prospective Payment System (OPPS) Manual Revision: Clarification of Coding and Payment for Drug Administration
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