astellasreimbursement

Payers may require healthcare providers to submit medical documentation along with claims submitted for services rendered to a patient. Additionally, healthcare providers may be expected to maintain specific types of documentation in the patient's medical record to be submitted to the payer for review upon request.

Maintaining and submitting proper medical documentation, as required by a payer, is an important part of managing the reimbursement process and helping to secure appropriate payment for services rendered. 

Below is a list of commonly requested medical documentation that may be requested when treating patients with AmBisome.

Common documentation on or with AmBisome claims submission

• ICD-9 diagnosis codes that document appropriate use of AmBisome
• When administered to Medicare patients by infusion pump in the home setting:
• An electronic copy of the DME Information Form (DIF) for External Infusion Pumps (CMS Form 10125) for an initial claim
• If a patient begins using an infusion pump for one drug and subsequently the drug is changed or another drug is added, a Revised DIF should be submitted for use of the pump with the new or additional drug. In the case of an additional drug, all drugs for which the pump is used should be included on the Revised DIF
• Use of appropriate modifiers to describe dispensing circumstances, for example:
• To denote that required documentation is being maintained: KX-Specific required documentation on file
• If orders are not yet on file: EY-No physician or other licensed healthcare provider order for this item or service

Common medical records documenting medical necessity for AmBisome

• Whether patient has suffered toxicity that precludes use of standard amphotericin B and laboratory test results that support this decision
• When administered by infusion pump in the home setting:
• An order for each item billed should be signed and dated by the treating physician, kept on file by the supplier, and made available upon request
• A DIF or other payer specific form which has been completed, signed, and dated by the supplier should be kept on file by the supplier and made available upon request
• Drug lot number
• Date the drug was ordered, when it was received by the provider, and the date it was administered to the patient