Billing Non-Chemotherapy Drugs
Injectable (non-chemotherapy) medications purchased and administered in the office are reimbursed using the appropriate HCPCS Drug Code and HCPCS billing units. Submission of a valid NDC, metric unit, and metric quantity are also required. HCPCS drug codes include J-codes, and certain A-codes, C-codes, Q codes, and S-codes. C-codes, Q codes, and S-codes may be activated for Medicaid claims in order to speed claim processing and avoid manual medical review.
If a HCPCS drug code is not available for non-chemotherapy drugs, bill procedure code J3490. Submission of a valid NDC, metric unit, and metric quantity are also required. See the requirement below. Code J3490 requires that the provider submit medical documentation with the claim indicating the drug, medical indication, dosage, route of administration, and the initials of the health care professional administering the drug. Without all of these
components documented, the claim will be denied.
These claims must be submitted to the fiscal agent. Fee-for-service claims are entered into the claims system for AHCA review and pricing. Please include the name of the drug on the CMS-1500 form, so that the AHCA reviewer can quickly identify the drug being billed and expedite processing of the claim.
Reimbursement for non-chemotherapy medications is determined according to the same pricing methodology used by Medicaid pharmacy services.
The non-specific drug codes (J3490, J3590) will still be required for Medicare B billing and subsequent crossover to Medicaid.
Note: See the Florida Medicaid Prescribed Drug Services Coverage and Limitations Handbook available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.
Non-FDA Approved Medications
Medicaid does not reimburse for non-FDA approved medications.
Medicaid does not reimburse procedures that are experimental or when non-FDA approved medications are included in the procedures.
Evaluation and Management Services
The cost of the injectable medication, if it is covered under Florida Medicaid, is reimbursable in addition to an evaluation and management (E&M) service.
E&M services are reimbursable in addition to the administration of an injectable medication, provided the visit is for a separate and identifiable service and the services are documented in the medical record.
Injectable Medication Services
, continuedFederal Rebate Agreement
Medicaid will only reimburse drugs for which the manufacturer has a federal rebate agreement per SEC. 1927 [42 U.S.C. 1396r-8]. The current list of manufacturers who have drug rebate agreements is available on AHCA’s Web site at www.ahca.myflorida.com. From the Site Menu, under Division of Medicaid, select Pharmacy Services.
Chelation Therapy Medicaid only reimburses medically necessary chelation therapy for recipients with known diagnosis of toxic substances. Laboratory documentation of the toxic substance must be maintained in the recipient’s medical record.
Medically Accepted Indications
To be reimbursed by Medicaid, a drug must be medically necessary and:
• Prescribed for medically accepted indications and dosages found in the drug labeling or drug compendia in accordance with Section 1927(k)(6) of the Social Security Act, or
• Prior authorized by a qualified clinical specialist approved by the Agency.
The Agency may exclude or otherwise restrict coverage of a drug in accordance with Section 1927 of the Social Security Act.
Outpatient-administered drugs fall under the jurisdiction of the Pharmaceutical and Therapeutics Committee and their recommendations, and Agency
decisions associated with the Preferred Drug List (PDL). See the Florida Medicaid Prescribed Drug Services Coverage and Limitations Handbook for discussion of PDL.
Note: The Prescribed Drug Services Coverage and Limitations Handbook is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.
Service Limitations Medicaid does not reimburse for investigational or experimental drugs as defined in Rule 59G-1.010, F.A.C.
Investigational use, for the purposes of Medicaid reimbursement, is defined as the use of a drug, whether an FDA approved drug or not, when that drug is used as an approved product in the context of a clinical study protocol, or the use of a product for an indication that is not supported by the current body of medical literature.
Medicaid does not cover any aspect of clinical trials, including radiology follow-up scans, laboratory procedures and any other medical testing, if the drugs are provided free of charge to the recipient.
Injectable Medication Services
, continuedNational Drug Code (NDC) Requirement
The National Drug Code (NDC) is required on all claims for drugs, including Medicare-Medicaid crossover claims. The NDC is required on the CMS-1500 claim form with the N4 qualifier on the appropriate electronic field. Claims received without the NDC will result in a denial. Submission of a valid NDC, metric unit, and metric quantity are required. The NDC number can be found on the product that is being administered to the patient. Medicaid utilizes the 11 digit format, and this may require insertion of leading zeros if they do not appear on the package (i.e., 00001-0234-05).
Note: Please see the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for instructions on entering the NDC on the claim. Medicaid handbooks are available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida. Select Public Information for Providers, then Provider Support, and then Provider Handbooks.
National Drug Code Crosswalk
The HCPCS to NDC crosswalk is published and updated quarterly by the Centers for Medicare and Medicaid (CMS). The crosswalk is accessible via the CMS Web site at www.cahabagba.com or at the following web address, www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/02.
Not all drugs listed on the CMS crosswalk are eligible for reimbursement by Florida Medicaid.
Drug Wastage Medicaid will reimburse for wastage of the unused portion of a single use vial, when the dosage and wastage is clearly documented in the medical record.
Medicaid will not reimburse medication wastage without proper
documentation. Medicaid will not reimburse for wastage for multi-dose vials.
Prior Authorization Requirements for IVIG
Intravenous Immune Globulin (IVIG) requires prior authorization. IVIG prior authorizations are managed through the Bureau of Pharmacy Services. The pharmacy clinical criteria for IVIG and the necessary prior authorization form can be found on the AHCA Web site at www.ahca.myflorida.com. From the Site Menu under the Division of Medicaid, select Pharmacy Services, next select Florida Medicaid Preferred Drug Program, and then Prior Authorization Requirements and Forms.
Botulinum Toxins Botulinum Toxins are reimbursed on a per unit basis.
Injectable Medication Services
, continuedEvaluation and Management in Addition to Botulinum Toxin
Intramuscular and subcutaneous injections are not reimbursable in addition to an evaluation and management procedure code.
Evaluation and management services are reimbursable in addition to the botulinum toxin treatment, provided that the visit is for a separate and identifiable service, and the services are documented in the medical record.
Injection of Botulinum Toxins
Injections must be reported one time per procedure, even if multiple
injections are performed in sites along a single muscle or if several muscles in a functional muscle group are injected. Bilateral procedures will be considered for reimbursement when the documentation clearly indicates bilateral anatomical sites (i.e., right arm, left arm).
Electromyography (EMG) with
Injectable Contrast Dye
Use of CPT codes 95869 or 95870 (limited EMG studies) may be considered for EMG guidance if the injection site is difficult to determine. Only one procedure per visit will be reimbursed based on sufficient, clear and concise medical documentation.
A routine electromyography (EMG) is not covered. For consideration of coverage, the physician must document in the medical notes that he had difficulty in determining the proper injections site(s) for botulinum toxin.
Excluded Services Medicaid does not reimburse injectable medication services for intraoperative services. Intraoperative services are a usual and necessary part of a surgical procedure. Examples are local anesthetic, digital block, or topical anesthesia.
These services are included in the payment for a global surgery and are not reimbursable in addition to the surgical procedure(s) 10000-69999.
Medicare Crossover Claims for J3490, J3590, and J9999
Medicare Crossover claims for J codes J3490, J3590, and J9999 are submitted from Medicare directly to the fiscal agent and are automatically paid by the system. Crossover claims for unclassified drugs do not come to AHCA for review and pricing.