Coverage Policy
The information displayed below pertains specifically to the Hospital Outpatient setting of care. For information tailored to the Physician Office setting or Pharmacy setting, please select the appropriate tab to the left or right. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Medicare
In general, Medicare considers subcutaneous injectable medications to be self-administered and, therefore, covered under Part D. However, Medicare covers FRAGMIN® under Part B when administered under a physician’s supervision and under Part D when dispensed for self-administration by a patient or caregiver. When provided as a Part B benefit, claims for FRAGMIN® are billed to contractors such as Fiscal Intermediaries (hospital outpatient setting), carriers (physician office setting) or the new Part A/B Medicare Administrative Contractors (MACs). Part D benefit claims for FRAGMIN® are billed to Part D plan sponsors. Providers should ensure that they are adhering to appropriate local contractor or Part D plan sponsor claim filing requirements when submitting claims for FRAGMIN®.
More information about Medicare Part B
More information about Medicare Part D
Payor Reimbursement1
FRAGMIN® is not eligible for separate payment under the Medicare Hospital Outpatient Prospective Payment System (OPPS). Rather, payment for FRAGMIN® is bundled into the payment for the outpatient visit.
Administration Services2
Drug administration Current Procedural Terminology (CPT) codes are assigned to Ambulatory Payment Classification (APC)s according to their clinical and resource requirements. Several drug administration codes may map to a single APC. APCs for drug administration services are updated yearly by CMS.
For more information on Medicare reimbursement for FRAGMIN®, contact your health plan.
1. Federal Register Vol. 76, No. 230. November 30, 2011. Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self- Referral; and Patient Notification Requirements in Provider Agreements. http://www.cms.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage. Accessed November 30, 2011.
2. Medicare Claims Processing Manual Chapter 4, Section 10.2 APC Payment Groups, and Section 230.2.C Payments For Drug Administration Services. Information available on http://www.cms.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912&intNumPerPage=10. Accessed February 16, 2011.
