For purpose of this exclusion, 'the term 'usually' means more than 50 percent of the time for all Medicare beneficiaries who use the drug.

The program covers drugs that are furnished 'incident-to' a physician's service provided that the drugs are not 'usually self-administered' by the patient.ĬMS has defined 'not usually self-administered' according to how the Medicare population as a whole uses the drug, not how an individual patient or physician may choose to use a

The Medicare program provides limited benefits for outpatient prescription drugs. Self-Administered Drug (SAD) Exclusion List articles list the CPT/HCPCS codes that are excluded from coverage under this category. Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period. The code lists in the article help explain which services (procedures) the related LCD applies to, the diagnosis codes for which the service is covered, or for which the service is not considered reasonable and necessary and therefore not covered.

MACs are Medicare contractors that develop LCDs and Articles along with processing of Medicare claims.īilling and Coding articles provide guidance for the related Local Coverage Determination (LCD)Īnd assist providers in submitting correct claims for payment.īilling and Coding articles typically include CPT/HCPCS procedure codes, ICD-10-CM diagnosis codes, as well as Bill Type, Revenue, and CPT/HCPCS Modifier codes. Articles often contain coding or other guidelines that complement a Local Coverage Determination (LCD). Local coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs).

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