Knowledge Base Article

I regret the paper pages of newspapers and books are becoming obsolete in today’s digital age. There was some comfort in holding the pages, smelling the print, and hearing the sound of crinkling paper as you read. Newsprint was important – movies set in the 20’s and 30’s often show the newsboy running through the streets shouting, “Special edition! Special edition! Read all about it!” Now we receive most of our “printed” news on-line or on our smart phones. But thanks to Medicare there are still “special editions.” Most of CMS’s MLN Matters Articles are based on recent transmittals (change request) – these are named based on the change request number beginning with the alpha characters “MM.” CMS also publishes Special Edition (SE) articles, generally to clarify existing regulations.

Two recent SE articles address prolonged drug infusions using an external pump and coverage of substance abuse services.

Prolonged Drug Infusions Via External Pump

On April 25, 2016, CMS released MLN Matters Article SE1609 clarifying Medicare’s policy for prolonged drug and biological infusions started incident to a physician's service using an external pump. There are times when hospitals or physicians’ offices may start an infusion using an external pump in the hospital outpatient or office setting of a drug they purchased, then send the patient home for a portion of the infusion and have the patient return to the clinic/office at the end of the infusion.   In these situations, the drug or biological and the drug/biological administration are billable to the Medicare Administrative Contractor (MAC). Also, payment for the external pump is included in the drug administration payment. The external pump may not be billed separately as Durable Medical Equipment to the DME MAC.   The MAC may direct use of a CPT or HCPCS code for the drug administration service that also accounts for the cost of external pump. This may be an unlisted code if no specific CPT or HCPCS code exists.

Medicare Coverage of Substance Abuse Services

There is not a distinct benefit category for substance abuse services but Medicare will cover medically necessary services for substance abuse as explained in the April 28th MLN Matters Article SE1604. The almost epidemic national opioid abuse make these services extremely important for Medicare beneficiaries. Medicare covers:

• Inpatient Treatment
• Medically necessary inpatient services, associated professional services, and medications (bundled into the inpatient payment).
• Outpatient Treatment
• Professional services such as counseling by an enrolled licensed clinical social worker, psychologist, or psychiatrist.
• Incident-to services of auxiliary personnel in certain settings (such as an outpatient hospital)
• Medications used in an outpatient setting that are not usually self-administered may be covered under Part B if they meet all Part B requirements.
• Note that substance abuse treatment facilities are not recognized by Medicare as an independent provider type. There is no integrated payment for the bundle of services these providers provide (either directly, or incident to a physician’s service).
• Partial Hospitalization Programs (PHP)
• Available in hospital outpatient department or Medicare certified Community Mental Health Center (CMHCs)
• Includes psychotherapy, occupational therapy, some activity therapies, family counseling, patient education/training, diagnostic services, and covered Part B medications.
• Supplier Services
• Suppliers such as physicians (medical doctor or doctor of osteopathy), clinical psychologists, clinical social workers, nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives may furnish substance abuse treatment services providing the services are reasonable and necessary and fall under their State scope of practice.
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
• Early intervention strategies for individuals with nondependent substance use prior to the need for more extensive or specialized treatment
• Easily used in primary care settings
• Consists of 1) Structured Assessment, 2) Brief Intervention, and 3) Referral to Treatment
• See Medicare's fact sheet, “Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services”
• Drugs Used to Treat Opioid Dependence
• Part D drugs medically necessary for the treatment of opioid dependence
• Medicare also covers laboratory drug testing services when necessary

Providers need to watch for Medicare MLN Matters Special Edition articles in order to stay informed about the latest changes to CMS Programs. Read all about it!