Fast, Easy Access to Medicare HCPCS Drug Information
First DataBank's Medicare Module — HCPCS Select speeds up and simplifies billing, processing, and auditing of Medicare reimbursement claims—including Part B. The Medicare drug content in this reliable database easily integrates into the claims-processing and billing systems of payers and providers alike.
Integrated Content Allows for Quick Claims Processing
Each week, millions of Medicare claims for drug products are processed nationwide. As more people turn age 65—and as patients and providers become more familiar with Medicare Part D—those numbers will increase dramatically.
But even without this expected increase, there are many instances today of coding errors, rejected claims, and slow reimbursement. The main reason for these problems is simple: while the data is usually good—typically drawn from the Center for Medicare and Medicaid Services’ (CMS) Health Care Products Coding System (HCPCS)—it is not typically integrated into healthcare information systems. The inefficiencies that result from manual claims processing waste both time and money.
First DataBank’s Medicare Module — HCPCS Select can help you quickly resolve these drug-product claims issues by providing an easily integrated electronic drug database that includes essential Medicare drug data you’ll need. Significant time and expense savings typically follow from improvements in formulary building, billing, coding, claims processing, and auditing.Comprehensive Medicare Drug Information Meets Your Every Need
Once integrated into your system, our Medicare drug database allows quick access to information on oral and injectable drugs that Medicare covers, both nationally and regionally. This information includes:
- Part B ASP information
- All drugs that are not administered orally
- Chemotherapy drugs
- Drugs with K codes for DMERC’s (Durable Medical Equipment Regional Carriers)
- Drugs with CMS temporary codes (Q Codes)
- Immunosuppressive drugs (oral and injectable)
- Some non-covered drugs to which CMS has assigned HCPCS codes
- Oral anti-cancer drugs that are National Drug Code (NDC)-specific (CMS will not accept these coded with HCPCS)
We identify all of these drug products as to whether they are:
- Not covered by Medicare
- Covered by Medicare
- Covered by Medicare with special instructions
- Covered by Medicare (DMERC’s) only with a certificate of medical necessity
Useful Price Types Facilitate Billing
The Medicare Module — HCPCS Select also includes a separate Medicare Part B table for CMS-covered drugs used during physician and outpatient services (such as physical and occupational therapy). The table includes CMS reimbursement figures for the covered drugs.
It’s often difficult for payers and providers to determine the appropriate charge for a particular drug, because HCPCS information neither follows a billing-unit standard, nor represents all drugs consistently. In response, First DataBank compiles average and median prices for all drug-related codes, to offer you our benchmark HCPCS Average Pricing Data for use as a reference. We assign each code in our database an average and median Average Wholesale Price (AWP), direct price and wholesale net price (also known as wholesale acquisition cost, or WAC). You can use these prices as a reference to help determine average ranges for a particular charge, or to aid in setting maximum allowable costs (MAC’s) claims. We update these prices monthly and reevaluate each year as new HCPCS information becomes available.
Also, we provide new pricing data for CMS Part B covered drugs, along with historical Single-Drug Pricer data from CMS.
Pricing information includes:
- Current HCPCS information
- Retired and reassigned HCPCS information
- Descriptions for drugs that CMS mandates as covered for all states for all applicable drug records
- Associated NDC data
- Part B information - average sales price (ASP) plus 6%, as provided by CMS
- Average and median benchmark prices: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DIR)
A Single Integrated Source for Medicare Information Simplifies Processing
Many of the data-handling problems that Medicare participants encounter are eliminated by our integration of multiple sources and standalone lists. By integrating these additional sources into our Medicare drug database, First DataBank fills several gaps in the Medicare information space, creating numerous advantages:
- NDC’s provide more detailed information on drug products than J Codes. Our databases allow users to link J codes to NDCs, and to connect HCPCS information with pricing data, enhancing information processing.
- J Codes (available from CMS) cannot be integrated into Medicare providers’ and payers’ healthcare information systems automatically. By integrating these codes and pricing data, we make Medicare claims processing more seamless.
- Both providers and payers need a reference for viewing Medicare Part B pricing data—the ASP set by CMS—to determine reimbursement levels. We include ASPs in our data.
- Medicare providers need an integrated reference for viewing NDC’s, J Codes and benchmark pricing to research billing issues. All three are available together in our Medicare drug database.
- Similarly, payers need to research reimbursement issues using J Codes and pricing data. They can, using our Medicare databases.
