Content Section
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Supplying Fee and Inhalation Drug Dispensing Fee Revisions and Clarifications
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MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Provider Types Affected
Physicians, providers, and suppliers billing oral anti-cancer chemotherapeutic drugs, oral anti-emetic drugs, immunosuppressive drugs, or inhalation drugs to Medicare durable medical equipment regional carriers (DMERCs) or fiscal intermediaries (FIs).
Provider Action Needed
This article is based on information contained in Change Request (CR) 3990, which clarifies and revises the policies and fees related to the supply fee and dispensing fee, and outlines changes to Healthcare Common Procedure Coding System (HCPCS) codes used for those fees.
Background
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, Section 303(e) (2)) authorized Medicare to pay a supplying fee for the following drugs:
- Immunosuppressive drugs,
- Oral anti-cancer chemotherapeutic drugs, and
- Oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen.
Supplying Fees
Effective January 1, 2006, Medicare will pay the following supplying fees to a pharmacy for each of the above listed drugs:
- $24 for the first prescription supplied to a beneficiary during a 30-day period. Each pharmacy that supplies the above listed drugs to a beneficiary during a 30-day period will be eligible for one $24 supplying fee in that period.
- $16 for each subsequent prescription of the above listed drugs supplied to a beneficiary in the same 30-day period.
Notes:
- In determining the number of face-to-face visits, the physician should not include face-to-face visits reported at 90935, 90937, 90945, or 99201-99356. Also, note that monthly capitation services may only be billed after the end of the month. For a refill prescription, Medicare will allow payment of a $24 supplying fee up to seven days before the end of the 30-day period for which the last $24 supplying fee was paid.
- A pharmacy will be limited to one $24 fee per 30-day period even if the pharmacy supplies more than one category of the above-mentioned drugs (for example, an oral anti-cancer drug and an oral anti-emetic drug) to a beneficiary. A supplier will not be allowed more than twelve $24 supplying fees per beneficiary per year.
- Medicare will pay a supplying fee for each prescription (including prescriptions for different strengths) of the same drug supplied on the same day. For example, Medicare will pay a supplying fee for both 1) a prescription for 100mg tablets and 2) a prescription for 5 mg tablets of the same drug supplied on the same day.
- This change does not alter the one-time $50 supplying fee (code Q0510 – replacement code for G0369) for the first immunosuppressive prescription after a transplant.
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Dispensing Fees
Medicare also pays a dispensing fee for inhalation drugs, in accordance with Section 1842(o)(2) of the Social Security Act. Effective January 1, 2006, Medicare will pay one dispensing fee to a pharmacy amounting to:
- $57 for an initial dispensing fee to a pharmacy for the initial 30-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time;
- One dispensing fee of $33 for a 30-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time; and
- One dispensing fee of $66 for each dispensed 90-day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time.
One Dispensing Fee Payment for 90-Day Period
Only one dispensing fee payment will be made for the 90-day period, regardless of the number of pharmacies used by a beneficiary. A supplier cannot be paid for more than one of the following for a beneficiary for the same period:
- An initial dispensing fee (G0333);
- A 30-day dispensing fee (Q0153); or
- A 90-day dispensing fee (Q0514.
Refill Prescriptions/Supply and Dispensing Fees
For a refill prescription, Medicare will allow payment of the dispensing fee no sooner than seven days before the end of usage for the current 30-day or 90-day script for which a dispensing fee was previously paid. An inhalation drug supplier will not be allowed more than 12 months of dispensing fees per beneficiary per year.
Note: The supply fee and dispensing fee must continue to be billed on the same claim as the drug supplied or dispensed. Also, note that a supply fee and a dispensing fee are not appropriate for one drug because:
- The supply fee is for immunosuppressives, oral anti-cancer drugs, and oral anti-emetic drugs; and
- The dispensing fee is for inhalation drugs only.
HCPCS Code Changes
Durable medical equipment regional carriers (DMERCs) and fiscal intermediaries (FIs) are instructed by CR3990 to recognize the following Healthcare Common Procedure Coding System (HCPCS) codes for:
- Supply fees for immunosuppressive, oral anti-cancer, and oral anti-emetic drugs:
- Code Q0510 (replaces G0369) – First immunosuppressive prescription after a transplant. ($50)
- Code Q0511 (replaces G0370) – Pharmacy supplying fee for immunosuppressive, oral-anticancer, and oral anti-emetic drugs, first prescription in a one-month period. Each pharmacy may receive this fee once in a 30-day period. ($24)
- Code Q0512 (replaces G0370) – Pharmacy supplying fee for immunosuppressive, oral anticancer, and oral anti-emetic drugs – each subsequent prescription in a 30-day period. ( $16)
- Dispensing fee for inhalation drugs(one per month) - Pay the first claim received for inhalation drugs:
- Code G0333 - Pharmacy dispensing fee for initial inhalation drug(s); initial 30-day supply to a beneficiary
- Code Q0513 (replaces G0371) - Pharmacy dispensing fee for inhalation drug(s); per 30 days. ($33)
- Code Q0514 (replaces G0374) - Pharmacy dispensing fee for inhalation drugs(s); per 90 days.($66)
A supplier cannot be paid for more than one of the above fees (G0333, Q0513, Q0514) for a beneficiary for the same period.
Note: Effective January 1, 2006, Medicare will no longer recognize codes G0369, G0370, G0371, and G0374. Also, the Medicare DMERC or FI will downcode G0333 to Q0513 and pay on the basis of Q0513 if a prior claim has been paid to any supplier for that beneficiary for inhalation drugs. Similarly, Medicare will downcode Q0511 to Q0512 if more than one claim for Q0511 is received from the supplier for a beneficiary during the 30-day period (except allowing for the refill within seven days of the end of the 30-day period). |
Implementation
The implementation date for the instruction is January 3, 2006.
Additional Information
For complete details, please see the official instruction issued to your FI or DMERC regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/  on the CMS Web site. From that Web page, look for CR3990 in the CR NUM column on the right, and click on the file for that CR.
If you have any questions, please contact your DMERC or FI at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
Related Change Request (CR) #: 3990
Medlearn Matters Number: MM3990
Related CR Release Date: November 10, 2005
Related CR Transmittal #: 754
Effective Date: January 1, 2006
Implementation Date: January 3, 2006
Posted: 12/13/2005
CPT codes, descriptions, and
other data only are copyright 2005 American Medical Association
(or such other date of publication of CPT). All Rights Reserved.
Applicable FARS/DFARS Apply.
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