DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for ...

CMS-1503-FC 975
supplier or any other person that bills for Part B covered drugs that are not paid under a
cost or prospective payment system. We did not propose to change the manner in which
we calculate ASP-based payment limits to reflect the setting in which the drug was
provided, and we believe that not only would such a policy be unduly complicated, but
also would likely be beyond our authority under the ASP statute. We note that regardless
of the benefit category for a drug or biological, if it is paid under section 1847A of the
Act, we calculate the payment limit without regard to overfill – thus, the fact that certain
providers or suppliers do not furnish drugs on an "incident to" basis is irrelevant to our
policy for the ASP calculation. This rule's scope is limited to the payment of overfill
under section 1847A of the Act.
Comment: One comment suggested that we encourage providers to the use
intentional overfill and bill Medicare only for the amount administered to the patient, but
not the wasted amount. The commenter also suggested that drug billing code increments
be reduced for those drugs that are dosed in smaller amounts than what is currently on the
billing code. For example, if a patient dose is 710mg but the billing increment is 100mg,
then the provider must bill Medicare for 800mg and waste the left over 90mg.
Response: We are continuing to work closely to review all billing codes to assure
that such codes describe drugs at the most clinically appropriate dosage descriptors. As
stated in the discarded drug policy (Chapter 17 Section 40 of the Medicare Claims
Processing Manual; http://www.cms.gov/manuals/downloads/clm104c17.pdf ), Medicare
will continue to make payment for the administered amount of drug plus any
appropriately discarded drug that sums to the labeled amount on a single-use vial or
package.