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Payment Limit (RHFMC)

Chuck Posted Tue 18th of February, 2014 11:28:49 AM

I have been researching some J Codes on your website. Would you be so kind as to explain to me what the term "payment limit" means with reference to J codes? For instance, CPT code J0696 has a payment limit of 0.728.
Thanks in advance for your help!

SuperCoder Answered Tue 18th of February, 2014 15:19:02 PM

In general, CMS establishes a single, national payment limit for FI, carrier, DME MAC,and A/B MAC payment for each Medicare-covered drug. Drugs billed to DME MACs are still priced locally, albeit under the new statutory formula, as applicable. The four DME MACs jointly establish drug payment limits for drugs that are billed to DME MACs.

The CMS provides an ASP file to each FI, carrier, DME MAC, and A/B MAC for pricing drugs. Each FI, carrier, DME MAC, and A/B MAC must accept the ASP files made available by CMS for pricing bills/claims for any drug identified on the price files.

The ASP drug pricing file shall contain 3 places after the decimal point in the currency field for the ASP file and contractors shall load the ASP file including 3 places after the decimal point. Contractors shall carry 3 places after the decimal point for the calculation of the amount due for a line item for each covered drug, then follow standard rounding procedures in determining the final allowance for that line item. The final allowed amounts will continue to carry 2 places after the decimal point.

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