October 2009 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
MLN Matters® Number: MM6585
Related Change Request (CR) #: 6585
Related CR Release Date: August 14, 2009
Effective Date: October 1, 2009
Related CR Transmittal #: R1795CP
Implementation Date: October 5, 2009
Provider Types Affected
All physicians, providers and suppliers who submit claims to Medicare contractors (Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs), carriers, Durable Medical Equipment Medicare Administrative Contractors (DME MACs) or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6585 and instructs Medicare contractors to download and implement the October 2009 ASP drug pricing file for Medicare Part B drugs; and if released by the Centers for Medicare & Medicaid Services (CMS), also the revised July 2009, April 2009, January 2009, and October 2008, files. Medicare will use the October 2009 ASP and not otherwise classified (NOC) drug pricing files to determine the payment limit for claims for separately payable Medicare Part B drugs processed or reprocessed on or after October 5, 2009 with dates of service October 1, 2009, through December 31, 2009. See the Background and Additional Information Sections of this article for further details regarding these changes.
Background
Section 303(c) of the Medicare Modernization Act of 2003 revised the payment methodology for Part B covered drugs and biologicals that are not paid on a cost or prospective payment basis. Beginning January 1, 2005, the vast majority of drugs and biologicals not paid on a cost or prospective payment basis are paid based on the ASP methodology, and pricing for compounded drugs has been performed by the local contractor.
ASP Methodology
In general, beginning January 1, 2005, the payment allowance limits for Medicare Part B drugs and biologicals that are not paid on a cost or prospective payment basis are 106 percent of the ASP. Further, beginning January 1, 2006, payment allowance limits are paid based on 106 percent of the ASP for:
- End Stage Renal Disease (ESRD) drugs (when separately billed by freestanding and hospital-based ESRD facilities); and
- Specified covered outpatient drugs and drugs and biologicals with pass-through status under the Outpatient Prospective Payment System (OPPS)
Beginning January 1, 2008, under the OPPS, payment allowance limits for specified covered outpatient drugs are paid at ASP+5 percent. Beginning January 1, 2009, under the OPPS, payment allowance limits for specified covered outpatient drugs are paid at ASP+4 percent. Drugs and biologicals with pass-through status under the OPPS continue to have a payment allowance limit of 106 percent of the ASP. CMS will update the payment allowance limits quarterly. There are exceptions to this general rule and they are stated in the Medicare Claims Processing Manual, Chapter 17, and Section 20.1.3 and may be reviewed at www.cms.hhs.gov/manuals/downloads/clm104c17.pdf (PDF, 484 KB).
Drugs Furnished During Filling or Refilling an Implantable Pump or Reservoir
Physicians (or a practitioner described in Section 1842(b) (18) (C) of the Social Security Act) may be paid for filling or refilling an implantable pump or reservoir when it is medically necessary for the physician (or other practitioner) to perform the service. Medicare contractors must find the use of the implantable pump or reservoir medically reasonable and necessary in order to allow payment for the professional service to fill or refill the implantable pump or reservoir and to allow payment for drugs furnished incident to the professional service.
If a physician (or other practitioner) is prescribing medication for a patient with an implantable pump, a nurse may refill the pump if the medication administered is accepted as a safe and effective treatment of the patient’s illness or injury; there is a medical reason that the medication cannot be taken orally; and the skills of the nurse are needed to infuse the medication safely and effectively. Payment for drugs furnished incident to the filling or refilling of an implantable pump or reservoir is determined under the ASP methodology as described above, except that pricing for compounded drugs is done by your local Medicare contractor.
Use of Quarterly Payment Files
The following table shows how the quarterly payment files will be applied:
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Files
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Effective Dates of Service
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October 2009 ASP and ASP NOC files
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October 1, 2009, through December 31, 2009
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July 2009 ASP and ASP NOC files
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July 1, 2009, through September 30, 2009
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April 2009 ASP and ASP NOC files
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April 1, 2009, through June 30, 2009
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January 2009 ASP and NOC Files
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January 1, 2009, through March 31, 2009
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October 2008 ASP and NOC Files
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October 1, 2008, through December 31, 2008
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NOTE: The absence or presence of a HCPCS code and its associated payment limit does not indicate Medicare coverage of the drug or biological. Similarly, the inclusion of a payment limit within a specific column does not indicate Medicare coverage of the drug in that specific category. The local Medicare contractor processing the claim shall make these determinations.
Additional Information
The official instruction (CR 6585) issued to Palmetto GBA, or DME MAC is available at
CMS would like providers to be aware that the following MLN products are available through the MLN Catalogue:
- The guide at www.cms.hhs.gov/MLNProducts/downloads/RA_Guide_Full_03-22-06.pdf (PDF, 12.30 MB) describes topics such as: types of Remittance Advice (RA), the purpose of the RA and types of codes that appear on the RA
- A fact sheet at www.cms.hhs.gov/PQRI/Downloads/PQRIEPrescribingFactSheet.pdf (PDF, 179 KB) introduces the E-Prescribing Incentive Program as authorized by Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
- The brochure at www.cms.hhs.gov/MLNProducts/downloads/Protectingpracbroch508-09.pdf (PDF, 183 KB) highlights some the steps providers can employ to protect their practices from inappropriate Medicare business interactions
If you have any questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.