The Centers for Medicare and Medicaid Services (CMS) is providing a clarification on billing for drugs under the Competitive Acquisition Program for Part B Drugs and Biologicals. In order for the CAP vendor’s drug claim to be processed and paid, physicians must submit a corresponding drug administration claim, and a no-pay claim line for the drug. The vendor’s drug claim and the physician’s claim are then matched in the claims processing system by the prescription order number, and the vendor is paid for the drug that was administered.

A physician’s no-pay claim line consists of the CAP drug’s HCPCS code, a billed amount (which must not equal zero), and the number of HCPCS billing units that were administered. The CAP prescription order number is a unique number generated by the approved CAP vendor that is used to match CAP claims in the payment system and is also associated with a line on an electronic claim. Therefore, the prescription order number should not be reused on additional lines of a claim or on other claims.

It has come to our attention that in some cases, drugs ordered under one, unique prescription order number are being billed on multiple claim lines and the prescription order number is being reused with the modifier 76 appended. This is causing CAP claims to not process correctly.

A CAP prescription order number must only be used on ONE claim line; it must not be reused on another claim line on the same claim or any other claim. If a CAP vendor has shipped a drug using one prescription order number but the drug is administered in several doses, the total amount administered should be identified in the number of billing units; for example:

The approved CAP vendor has shipped 20 Heparin units of J1642 Heparin Sodium (Heparin Lock Flush) under the prescription order number QXXXJ1642YYYYY. The patient’s IV lines required two 10-unit heparin flushes during the course of the office visit. Since the HCPCS code defines J1642 as 10 units of heparin and a total of 20 units of heparin were administered, this situation would be billed as 2 billing units of J1642 on a line containing a J1 no-pay CAP modifier and associated with prescription order number QXXXJ1642YYYYY.

For additional information about CAP billing, refer to the billing tip sheet on the CMS Web site at www.cms.hhs.gov/CompetitiveAcquisforBios/Downloads/cap_billtips.pdf.

CMS Learn Resource PE200611-11

Posted: 11/17/2006

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