March 5, 2021 – Revised: 12.01.22
Drug Administration Reminder
As a reminder, in order to be processed for consideration, the drug or biological must meet all the general requirements for coverage under the incident-to provision. An FDA approved drug or biological must:
- Be of a form that is not usually self-administered.
- Must be furnished by a physician; and
- Must be administered by the physician, or by auxiliary personnel employed by the physician and under the physician's personal supervision.
The charge, if any, for the drug or biological must be included in the physician's bill, and the cost of the drug or biological must represent an expense to the physician.
Beneficiaries should not incur the expense of a covered Part B covered drug or biological as a cost saving measure for the physician's office.
If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury, CGS will deny coverage for both the drug and its administration. Also, CGS will deny any charges for other services (i.e. office visit) rendered for the purpose of administering a non-covered injection.
No Cost Drugs:
If the provider has received a drug at no-cost or the patient brings in the drug, the appropriate drug code must be submitted with a nominal fee of $0.01 (one cent), with the appropriate administration code.
For example, the administration may be covered for certain self-administered drugs, if the patient's condition prevents them from administering the drug themselves. The documentation must clearly show evidence why the administration is needed by the practitioner or auxiliary personnel. Refer to the Self-Administered Drug Exclusion List: and Biologicals Excluded from Coverage - Medical Policy Article (A52527)
for additional guidance and billing instructions.
Billing Instructions for No Cost Drugs:
- The appropriate HCPCS drug code must be submitted, with the administration code. The submitted amount must also be one cent.
- Providers must indicate the following in the 2400/SV101-7 data element, or Item 19 of the CMS 1500 form:
- Loop 2400 Segment SV101-7 for the 5010A1 837P or Item 19
- Enter "Patient Purchased" or "No Cost Drug"
- Enter code description, strength, and dosage – if billing a Not Otherwise Classified (NOC) HCPCS
- Loop 2400 Segment SV101-2 or Item 24D
- Enter drug (HCPCS) code
- Loop 2300 CLM02 or Item 28
- Enter $0.01 for the billed
- Loop 2400 Segment SV101-7 for the 5010A1 837P or Item 19
References:
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