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Self-Administered Drugs

Understand Medicare drug coverage rules and risk areas for accurate claims submission and information reporting. Learn about self-administered drugs and common outpatient risk factors.

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Self-Administered Drugs

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  1. Self-Administered Drugs • Drugs that can usually be self-administered are not covered by Medicare • “Usually” means more than 50 percent of the time the drug is used by Medicare beneficiaries (Source: CMS Program Memorandum AB-02-072)

  2. Submission of accurate claims and information OIG Supplemental Guidelines

  3. Outpatient Risk Areas - APC • Improper coding • Improper modifiers • Inpatient-only procedures • Medically unnecessary services • Outdated Charge Masters

  4. Outpatient Risk Areas - CAH • Erroneous cost reporting • Improper billing of Observation services • Outdated Charge Master • Medical necessity issues • Incorrect provider-based designation

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