Pharmacy Billing of Immunosuppressive Drugs
Change Request (CR) 10235 highlighted updated language in the Medicare Claims Processing
Manual, Chapter 17, Section 80.3. (Billing for Immunosuppressive Drugs) regarding the use of the
KX modifier for certain claims for immunosuppressive drugs. See the related MLN Matters article
(MM10235) at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM10235.pdf. CR10235 also provided guidance to the MACs
to abide by the updated language on processing claims for immunosuppressive drugs.
This article reminds pharmacy billing staff of the appropriate process for billing Medicare for
immunosuppressive drugs using the KX modifier. This is especially important for pharmacies as the
Health and Human Services Office of the Inspector General (OIG) recently determined that
pharmacies did not comply with parts of this policy on a significant percentage of related claims. Be
sure your staff is aware of the proper policy as summarized in the Background Section of this article.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: March 28, 2018
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.