BYOD - Bring your Own Drugs?

By Sandra Jones, Ambulatory Strategies Inc.
[email protected]

Question:

My doctors want to use a medication which is very expensive for a procedure. They heard at a physicians’ meeting that they could write a prescription for the patients to get the medication at a pharmacy where the patients would pay for it. Then the patients would be instructed to bring the medication to the surgery center where staff would administer it.  Is this an acceptable practice?  What about possible drug contamination if the patient opens it before arriving at the surgery center? What other things should I be concerned about?

Answer:

This question was recently posted on a website. Some persons responding to the question mentioned concern about sterility of the drugs, whether the patient kept the mediation at the correct temperature as stated on the medication container or on the information insert, and what to do if the patient does not bring the medication as prescribed, either failing to get the prescription filled or forgetting to bring the medication on the day of the procedure.

While these are all important issues for medication safety, a significant concern is whether this is compliant with a payer agreement.   Medicare and many managed care contracts pay a fee by CPT and specify that the payment includes supplies, medications, the use of the facility and other items.  For full details, the Medicare Claims Processing Manual for Ambulatory Surgery Centers may be useful to review.  This guide can be obtained at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c14.pdf.

In this Medicare manual, CMS states that payment covers a group of services and supplies. Included facility services are:

1.    Nursing, technician, and related services;
2.    Use of the facility where the surgical procedures are performed;
3.    Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver;
4.    Drugs and biologicals for which separate payment is not allowed under the hospital outpatient prospective payment system (OPPS);
5.    Medical and surgical supplies not on pass-through status under Subpart G of Part 419 of 42 CFR;
6.    Equipment;
7.    Surgical dressings;
8.    Implanted prosthetic devices, including intraocular lenses (IOLs), and related accessories and supplies not on pass-through status under Subpart G of Part 419 of 42 CFR;
9.    Implanted DME and related accessories and supplies not on pass-through status under Subpart G of Part 419of 42 CFR;
10.    Splints and casts and related devices;
11.    Radiology services for which separate payment is not allowed under the OPPS, and other diagnostic tests or interpretive services that are integral to a surgical procedure;
12.    Administrative, recordkeeping and housekeeping items and services;
13.    Materials, including supplies and equipment for the administration and monitoring of anesthesia; and
14.    Supervision of the services of an anesthetist by the operating surgeon.


The CMS Manual explains each of the above items in detail including that there are some exceptions. However, drugs that are covered, in general, include those that cannot be self-administered.

In addition to being concerned about medical safety, reviewing the Medicare Claims Processing Manual for ASCs may be an important step when assessing whether the patient or the facility pays for a supply or drug.