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NEW DRUG COVERAGE FOR NOVITAS SOLUTIONS JH STATES
After a number of requests to provide new drug coverage information for practices in OK, TX, NM, CO, LA, MS, AR
to allow them to know when a practice has gotten reimbursed for the new drug, I contacted Novitas Solutions to
see if there was a way we could do so. This is the response I received:
Novitas addresses coding new drugs in our JH Local Coverage Article A52018 Approved Drugs and Biologicals;
Includes Cancer Chemotherapeutic Agents. Not Otherwise Classified (NOC) codes should only be reported for
those drugs that do not have a valid HCPCS code which describes the drug being administered. When appropriate,
the NOC code is selected based upon the therapeutic value of the drug (e.g., J8999 Prescription drug, oral,
chemotherapeutic, NOS; J3490 Unclassified drugs, etc.). When billing with an NOC code, include on the claim, the
narrative description reflective of the agent and the dose administered.
I also wanted to direct you to the New Drug Code Pricing section of our website. This section describe the fee
development process by the Novitas Solutions Pricing Committee when a new drug is FDA approved and there are
no fees included in the ASP Medicare Part B Drug Pricing File or Not Otherwise Classified (NOC) Pricing File.
In the absence of a Local Coverage Determination (LCD), National Coverage Determination (NCD), or CMS Manual
Instruction, Reasonable and Necessary guidelines still apply. Section 1862(a)(1)(A) of the Social Security Act (SSA)
directs the following:
"No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable
and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body
member."
Therefore, to be considered "reasonable and necessary" the patient's medical record must clearly document all of
the following:
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The item or service is for the diagnosis or treatment, or to improve the functioning of a malformed body
member
The item or service is appropriate for the symptoms and diagnosis or treatment of the patient's condition,
illness, disease or injury
The item or service is furnished in accordance with current standards of good medical practice
The item or service is not primarily for the convenience of the patient or physician or health
care provider
The item or service is the most appropriate supply or level of service that can be safely provided to the
patient
The item or service is delivered in the most appropriate setting
The item or service is ordered and/or furnished by qualified personnel
For any service reported to Medicare, it is expected that the medical record documentation clearly demonstrates
that the service meets all of the above criteria. All documentation must be maintained in the patient's medical
record and be available to the contractor upon request.
Heidi DeDay CPC, CEMC
CMD Research Analyst, Medical Affairs
Novitas Solutions, Inc.
Mary Jo Richards
918-261-8951