CMS Pub. 100-04, ch. 10, § 90.1

A. Billing Requirements

The administration of the drug is included in the charge for the skilled nursing visit billed

using TOB 032x. The cost of the drug is billed using TOB 034x, using revenue code

0636. These drugs are paid on a reasonable cost basis, using the provider’s submitted

charges to make initial payments, which are subject to annual cost settlement.

Coverage requirements for osteoporosis drugs are found in Pub. 100-02, Medicare

Benefit Policy Manual, chapter 7, section 50.4.3. Coverage requirements for the home

health benefit in general are found in Pub. 100-02, Medicare Benefit Policy Manual,

chapter 7, section 30.

Drugs that have the ingredient calcitonin are billed using HCPCS code J0630. HCPCS

code J0630 is defined as up to 400 units. Therefore, the provider must calculate units for

the bill as follows:

Units Furnished

During Billing

Period

Units of

Service

Entry on

Bill

100-400 1

401-800 2

801-1200 3

1201-1600 4

1601-2000 5

2001-2400 6

Drugs that have the ingredient teriparatide may be billed using HCPCS code J3110, if all

existing guidelines for coverage under the home health benefit are met. HCPCS code

J3110 is defined as 10 mcg. Providers should report 1 unit for each 10 mcg dose

provided during the billing period.

Drugs that have the ingredient denosumab are billed using HCPCS code J0897, if all

existing guidelines for coverage under the home health benefit are met. HCPCS code

J0897 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provided

during the billing period.

Drugs that have the ingredients romosozumab-aqqg are billed using HCPCS code J3111,

if all existing guidelines for coverage under the home health benefit are met. HCPCS

code J311 is defined as 1 mg. Providers should report 1 unit for each 1 mg dose provided

during the billing period.

Drugs that have the ingredient abaloparatide are billed using HCPCS code J3590

(unclassified biologics), if all existing guidelines for coverage under the home health

benefit are met. As an unclassified code, HCPCS code J3590 does have not a standard

definition for units. Providers should report 1 unit for each 80 mcg dose provided during

the billing period.

All other osteoporosis drugs that are FDA approved and are awaiting a HCPCS code

must use the miscellaneous code of J3490 until a specific HCPCS code is approved for

use.

B. Edits

Medicare system edits require that the date of service on a 034x claim for covered

osteoporosis drugs falls within the start and end dates of an existing home health PPS

episode. Once the system ensures the service dates on the 034x claim fall within an HH

PPS episode that is open for the beneficiary on CWF, CWF edits to assure that the

provider number on the 034x claim matches the provider number on the episode file.

This is to reflect that although the osteoporosis drug is paid separately from the HH PPS

episode rate it is included in consolidated billing requirements (see §10.1.25 regarding

consolidated billing).

Claims are also edited to assure that if the claim is an HH claim (TOB 034x), the

beneficiary is female and that the diagnosis code for post-menopausal osteoporosis is

present.