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July 14, 2014 – Updated 12.14.21

Immunosuppressive Drugs: Submit Claims to the Correct Contractor

Claims for immunosuppressive drugs must be submitted to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for reimbursement. Do not submit these claims to your Part B MAC.

  • The DME MAC for Kentucky and Ohio (Region B) is CGS Administrators, Jurisdiction JB.

Coverage:

  • Medicare covers a beneficiary's immunosuppressive drugs following an organ transplant, provided that the beneficiary receiving the drug was enrolled in Medicare Part A at the time of the organ transplant procedure.
  • Medicare will pay for medically necessary immunosuppressive drugs for such a beneficiary whether or not Medicare paid for the transplant itself.
  • Refer to the CGS JB Immunosuppressive Drugs Local Coverage Determination for more information and coverage criteria.

Claim submission for physician's management of immunosuppressive therapy:

  • Submit claims for the physician's management of immunosuppressive therapy to CGS, under Part B, using the appropriate level of Evaluation & Management (E/M) code.
  • Charges for the physician's management of immunosuppressive therapy are not part of the global surgery package, meaning that E/M services to manage immunosuppressive therapy by the surgeon may be reimbursed separately even when they are provided in the follow-up period of the transplant. Submit these services with CPT modifier 24 and indicate "immunosuppressive therapy management":
    • Electronic claims: Loop 2400, NTE02, or SV101-7 field
    • Paper claims: Item 19

Reference:

Reviewed: 12.13.22

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