Drugs|Pharmaceuticals|FDA - Articles

New Modifier Required on all Single-Use Drugs
February 13th, 2023 - Chris Woolstenhulme
Attention providers and suppliers, there is a new modifier in town! Starting July 1, 2023, Modifier JZ - Zero Drug wasted will be required on all claims to attest there is no drug leftover, If applicable.

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Reporting and Auditing Drug Testing Services
November 9th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT
Drug testing is a common medical service used to manage prescription medications, verify someone is not taking illegal substances or too much of a prescribed substance, and monitor for toxicity and therapeutic dosing. It is customary for patients in treatment programs for chronic pain management or substance use disorders (SUD) to undergo random urine drug testing (UDT) or urine drug screening (UDS) as part of their individual treatment plan. Drug testing is regulated by federal and state laws (e.g., OSHA, CLIA), which must be carefully adhered to.
Packaging and Units for Billing Drugs
May 18th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number. Take a look at the following J1071 - Injection, testosterone cypionate, 1mg For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL (100 mg/mL = 1 mL and there are ...
Clarify the Complexity Please! NDC Codes and Drug Classification Systems
April 20th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...
Medicare Part D Coverage Gap (Donut Hole) Closes in 2020
March 26th, 2020 - Jared Staheli
Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.
2020 Medicare Part D Coverage Gap (AKA donut hole)
March 26th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...
Wolters Kluwer Drug Pricing
October 17th, 2018 - Find-A-Code
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
July 9th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Medicare sent out a news release to inform of incorrect reimbursement and correction. "End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they: Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and Contain non-covered charges After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
Inappropriate Use of Units Costs Practice Over $800,000
June 11th, 2018 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
Indications for Serotypes A and B Botulinum Toxins
April 16th, 2018 - Find-A-Code
According to Novitas LCD L27476, the following indications apply: 1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
Understanding The Healthcare Fraud Prevention Partnership's Commitment to the Management of Opioid Misuse and Opioid Use Disorder
February 27th, 2018 - Jared Staheli
The opioid epidemic continues to ravage communities nationwide. Since 1999, opioid deaths have quadrupled. 91 Americans die every day from opioid overdoses, and these numbers show no signs of declining. To address an epidemic of this magnitude, unprecedented cooperation between all involved parties needs to occur. In January 2017, CMS released a ...
Dental and Medical- Controlled Substance Awareness
January 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
Prescription Drug Discount Program
January 25th, 2018 - Wyn Staheli, Director of Research
Prescription drugs can be quite costly for those who are uninsured or underinsured. Prohibitive costs have been shown to lead to poor patient outcomes because medications are not taken as prescribed. Medicare has taken steps to address this problem with their Medicare Advantage value based plans (see referenced "Medicare Expands Value ...
HIPAA and the Opioid Crisis
January 24th, 2018 - Wyn Staheli, Director of Research
HIPAA and the Opioid Crisis guidance released by HHS.
$4.6 million in Claims Paid Incorrectly by CMS when Using KX Modifier
January 16th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements.  The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B ...
Medicare Reimburses for Discarded/Wasted Drugs
January 5th, 2018 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
Your organization may be leaking revenue without realizing the leak can be stopped. If your organization purchases single-use packets or single dose vials for individual patient use and ends up discarding some of the drug, Medicare has now authorized payment for the discarded or wasted portion. Stop leaking revenue today by reading this article and implementing the guidance provided here.
Average Wholesale Price (AWP)
November 17th, 2017 - David Berky
Clinical Drug Information, LLC Average Wholesale Price (AWP) is intended only to be used by Clinical Drug Information, LLC customers. While many use this information as a price index, the Clinical Drug Information, LLC AWP does not represent an average of wholesale prices from any group of transactions in the ...
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
August 4th, 2017 - Chris Woolstenhulme, CPC, CMRS
This is a list of some of the most common Injectable unclassified drugs used with J3490 Antilirium – 1 mg/ml Ascorbic Acid – 500 mg/ml Ascorbic Acid – 250 mg/ml Bacitracin, Intramuscular – 50,000 unit vials Bacitracin, Intramuscular – 10,000 unit vials Brevital Sodium – 500 mg/5 ml Caffeine and Sodium Benzoate – 250 mg/ml Capastat Sulfate – 1 ...
Prescription Drug Management: Is it a Level 3 or a Level 4?
June 29th, 2017 - J. Paul Spencer, CPC, COC
If you place four auditors around a table and place a typical established patient visit in front of them, what tends to follow is a scene that resembles less about building consensus and more along the lines of a National Geographic special regarding the hunting habits of hyenas. Perhaps no ...
Modifier JW With Drug Codes
June 27th, 2017 - Find-A-Code
Modifier JW In the past, some Medicare Administrative Contractors have required providers to report wasted drugs with modifier JW (Drug amount discarded/not administered to any patient). Use of the modifier was at the contractor’s discretion, and some contractors told providers not to report it. But effective January 1, 2017, all providers ...
April 28th, 2017 - Christine Taxin
Prescribers, including dentists, who write prescriptions for Part D drugs are to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D. Full enforcement of Part D prescriber enrollment requirement will begin on January 1, 2019. ...
New and Deleted Drug Screen codes for 2017
January 23rd, 2017 - Chris Woolstenhulme, CPC, CMRS
Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017. Deleted Codes for 2017 80300   Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...
Which Drugs Require Intensive Monitoring for Toxicity?
March 22nd, 2013 - Seth Canterbury, CPC, ACS-E/M
Question: When coding E/M services, what drugs qualify as those requiring “intensive monitoring for toxicity” on the MDM Risk table? Answer: Therapeutic drug monitoring is required for a variety of reasons, one of which is a drug’s high potential for toxicity. Intensive monitoring for...

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