Oncology & Hematology Coding Alert

Question: I’m new to medical coding. I read something about not charging Part B for drugs that are usually self-administered, but how do you know whether a drug falls in that category?

Tennessee Subscriber

Answer: The list of self-administered drugs (SAD) is determined by each Medicare contractor, so you have to check the list for the particular payer you’re reporting to.

To find the list, check the specific payer’s site, or search for that payer’s SAD article on the Medicare Coverage Database (MCD). In some cases, the payer’s site will take you directly to its article on the MCD.

Tennessee example: Cahaba’s SAD Exclusion site for Part B is at www.cahabagba.com/part-b/medical-review/self-administered-drug-sad-exclusion-list/. On the site, there’s a SAD List link for J10 MAC B Tennessee. Click the link, and you’ll be taken to an MCD page. Click the link for the article "Self-Administered Drug Exclusion List -- J10 MAC" (A48903). You may need to accept license agreements to continue.

The article includes the SAD list (codes, brand names, etc.). For example, the list includes J9213 (Injection, interferon, alfa-2a, recombinant, 3 million units) for Roferon-A, which physicians may prescribe to treat conditions such as hairy cell leukemia, AIDS-related Kaposi’s sarcoma, or chronic myelogenous leukemia (CML).

Alternatively, you may go directly to the MCD at www.cms.gov/medicare-coverage-database/. There are a few ways to get to the information you need, but one option is to choose "Advanced Search." Under "Search by Document Type," select "Local Coverage Documents." Then check "SAD Exclusion Articles" as the type of document you’re searching for. Choose your geographic area or contractor, and set the date criteria to "Currently in effect."

SAD: The Cahaba site explains, "If the Contractor determines that a given drug is ‘usually self-administered,’ it cannot be covered by Medicare under any circumstance, regardless of whether the drug is administered by a physician or anyone else." However, you’ll find that the list also includes a few drugs marked with this note: "Code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered." There are five items on the Cahaba list noted to have this exception, as of this publication.