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Billing a Miscellaneous/ Unclassified HCPCS Code 60889-R5-V1 • 2 This information Thi i f ti is i provided id d for f your background b k d education d ti and 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