Download Billing a Miscellaneous/ Unclassified HCPCS Code Unclassified

Billing a Miscellaneous/
Unclassified HCPCS Code
60889-R5-V1
•
2
This information
Thi
i f
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i provided
id d for
f your background
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d
is not intended to serve as guidance for specific coding, billing,
and claims submissions. The decision on which codes best
describe the services provided must be made by the individual
providers based on specific payor guidance and requirements.
Overview
• Billing and coding for miscellaneous HCPCS*
HCPCS codes
• Medicare
• Medicaid
• Private payors
•
Claim form submission
• Sample CMS-1500
• Sample UB-04/CMS-1450
• Tips for submitting a clean claim
*HCPCS – Healthcare Common Procedure Coding System
Unclassified/Miscellaneous Codes
• Used when no existing national code adequately
•
•
1.
describes the item or service being billed
Allows suppliers to begin billing immediately for a
service or item as soon as the Food and Drug
Administration (FDA) allows it to be marketed
U dd
i th
i d off titime a requestt ffor a
Used
during
the period
new code is being considered under the HCPCS
review process1
CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.
http://www.cms.gov/MedHCPCSGenInfo/02_HCPCSCODINGPROCESS.asp. Accessed 05/02/2010.
Coding for Physician Administered Drugs
• Drugs are typically reported
•
using product specific
HCPCS codes (eg
(eg, JJ-code)
code)
assigned by the Centers for
Medicare & Medicaid
Services (CMS)2
Until a specific code is
assigned, an “unclassified”
code is normally used
HCPCS
Code1
Descriptor
J3490
Unclassified drugs
g
J3590
Unclassified biologics
J9999
Not otherwise classified,
f
antineoplastic drugs
C9399
Unclassified drugs or
biologicals
(Medicare hospital
outpatient setting)
1. Centers for Medicare and Medicaid Services, 2012 Alpha Numeric HCPS HCPCS File.
http://www.cms.gov/HCPCSReleaseCodeSets/Downloads/12anweb.zip. Accessed January, 23, 2012.
2.
CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.
http://www.cms.gov/MedHCPCSGenInfo/02_HCPCSCODINGPROCESS.asp. Accessed 9/29/2010
Miscellaneous Coding Implications1
Additional
information
required by
most p
payors
y
on
claim form may
include:
Some payors
may
y also
request:
• Drug name/generic name
• Strength
• Dosage administered
• Route of administration
• National Drug Code (NDC)
• Prescribing Information
• FDA-approval letter
• Any relevant documentation to
support
pp
medical necessity
y (chart
(
or
laboratory notes, letter of medical
necessity, etc)
• Drug purchase invoice
1. WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips.
http://www.wpsmedicare.com/j5macpartb/departments/claims/j3490billingtips.shtml . Accessed 11/25/2010.
6
Medicaid - Billing Unclassified HCPCS Codes
Physician Office
• Bill on the CMS-1500 or electronic
equivalent
• Example
E ample HCPCS:
HCPCS J3590 or J3490
• NDC is required on Medicaid claims
including the paper CMS-1500,
electronic 837P
837P, Web interChange
claims and Medicare crossover claims
– Reporting instructions vary by payor
Providers typically need to report
the NDC in the national
11-digit
g format of 5-4-2
Example:
13456-123-12
would be reported as
12345012312
1 Centers for Medicare & Medicaid Ser
1.
Services
ices (CMS)
(CMS), Transmittal 1401
1401. www.cms.gov/transmittals/downloads/R1401CP.pdf.
cms go /transmittals/do nloads/R1401CP pdf
Accessed 06/03/2010.
2. WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips.
http://www.wpsmedicare.com/j5macpartb/departments/claims/j3490billingtips.shtml. Accessed.:06/22/2010.
Private Payors - Billing Unclassified
HCPCS Codes
Physician Office
• Bill on the CMS-1500 or electronic
equivalent.
Example:
– J3590 Unclassified biologics
g
– J3490 Unclassified drugs
• Additional information required in
Box 19 will vary by payor
Hospital Outpatient
• Bill on the UB-04/CMS-1450
or electronic equivalent.
Example:
– J3590 Unclassified biologics
g
– J3490 Unclassified drugs
• Additional information required
in Field 80 (Remarks) will vary
by payor
Centers for Medicare and Medicaid Services, Transmittal 1924, February 26, 2010.
http://www.cms.hhs.gov/transmittals/downloads/R1924CP.pdf. Accessed November 24,2010.
EXAMPLE CLAIM FORMS
Physician Office: Sample CMS-1500
Box 19: List drug name
(brand/generic), dosage, route of
administration, and NDC
Brand Name (generic name), dose, administered, NDC XXXXXXXXXXX
XXX XX
Box 21: Enter ICD-9-CM diagnosis
code based on the patient’s
documented medical record
XXX XX
96372
J3490
Box 24 D: Enter CPT / HCPCS code(s)
for procedure and other services
provided
Hospital Outpatient: Sample UB-04
96372
Field 44: Enter HCPCS /
CPT code(s) for procedures
and other services provided
J3490
Field 69: Enter ICD-9-CM
diagnosis code(s) based on
documentation in medical
record
Field 80: List drug name,
(brand/generic) dosage, and
NDC
XXX
Brand (generic), dose, route of
administration, NDC XXXXXXXXXXX
Reasons for Claim Denial
Common reasons iinclude:
C
l d
• Incorrect or transposed patient information
(eg, insurance identification number, date of birth)
•
•
•
•
•
Invalid codes – CPT, HCPCS, ICD-9-CM
Missing or incorrect number of units
I
Incorrect
t modifier
difi or lack
l k off a modifier
difi
Service not deemed a medical necessity
Insufficient information to p
process the claim
(eg, missing NDC, prior authorization number, invalid NPI)
• Site of service mismatch
12
Billing correctly the first time may prevent a delay in processing your claim
.
13
•
Provide appropriate documentation in the
patient’s medical record to justify the coding
•
If submitting an unclassified/miscellaneous code
code,
include additional information as required by the
payor
•
Verifyy yyour computer
p
software is current and
consistent with built-in edits
•
Track clearinghouse claims to ensure successful
transmission
•
Monitor payor coding and coverage policies