Self-Administration of Drugs or Biologicals and Recovery Audit Contractors (RAC)

CMS recently released Transmittal 123 (Change Request 6950) on April 30, 2010 on Determining Self-Administration of Drugs or Biologicals which took effect on April 30, 2010. Transmittal 123 provided contractors with updates to manual language related to the determination of self-administration of drugs and biologicals, to allow for other routes of administration besides injections to be considered as not usually self-administered based on some new drugs that were approved by the Food and Drug Administration.

Hospitals have struggled for years with the concept of “self-administrable” drugs for Medicare beneficiaries and how to identify and bill them since they are not covered by Medicare. Based upon that fact alone it becomes a potential target for RACs.

To start with some history, the Medicare program covers drugs that are furnished “incident to” a physician’s service provided that the drugs are not usually self-administered by the patients who take them (refer to Pub. 100-02, Medicare Benefit Policy Manual). In the updated regulation, under the heading “Administration,” it now reads; “The term “administrated” refers only to the physical process by which the drug enters the patient’s body. It does not refer to whether the process is supervised by a medical professional (for example, to observe proper technique or side effects of the drug). Injectable drugs, including intravenously administered drugs, are typically eligible for inclusion under the “incident to” benefit. With limited exceptions, other routes of administration including, but not limited to oral drugs, suppositories, topical medications, are considered to be usually self-administered by the patient.

Based upon this revision, and to prepare for potential audits, facilities should be sure to review outpatient departments within your hospital, including provider-based status departments, where infusions are provided, to determine if this change in verbiage related to “intravenous infusions” is impacted by the self-administrable benefit policy.This will allow you to address changes in charge capture, coding and billing processes that may be required to be compliant with Medicare reporting requirements.

Written by Kim Charland, BA, RHIT, CCS