General Question for the Week of October 28, 2024

Question:

Under what circumstances does Medicare provide coverage for drugs or biologicals, and how is the determination made regarding whether a drug is considered “not usually self-administered”?

Answer:

Medicare coverage is usually limited to drugs or biologicals administered by infusion or injection. These injectable or intravenous drugs are administered predominantly by a physician or in the hospital setting under a physician’s general supervision as “incident to” a physician’s professional service. The statute limits coverage for drugs that are not usually self-administered. If a drug is not self-administered by more than 50 percent of the time for all Medicare beneficiaries, it is considered “not usually self-administered.

This question was answered in our Coding Essentials for Infusion & Injection Therapy Services. For more hot topics relating to infusion services, please visit our store or call us at 1.800.252.1578, ext. 2.