60889-R5-V1. Billing a Miscellaneous/

Transcription

1 60889-R5-V1 Billing a Miscellaneous/ Unclassified HCPCS Code

2 This information is provided d for your background education and 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. 2

3 Overview Billing and coding for miscellaneous 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

4 Unclassified/Miscellaneous Codes Used when no existing national code adequately 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 Used during the period of time a request for a new code is being considered under the HCPCS review process 1 1. CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures. Accessed 05/02/2010.

5 Coding for Physician Administered Drugs Drugs are typically reported using product specific HCPCS codes (eg, J-code) assigned by the Centers for Medicare & Medicaid Services (CMS) 2 Until a specific code is assigned, an unclassified code is normally used HCPCS Code 1 J3490 J3590 J9999 C9399 Descriptor Unclassified drugs Unclassified biologics Not otherwise classified, antineoplastic drugs Unclassified drugs or biologicals (Medicare hospital outpatient setting) 1. Centers for Medicare and Medicaid Services, 2012 Alpha Numeric HCPS HCPCS File. Accessed January, 23, CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures. Accessed 9/29/2010

6 Miscellaneous Coding Implications 1 Additional information required by most payors on claim form may include: Drug name/generic name Strength Dosage administered Route of administration National Drug Code (NDC) Prescribing Information FDA-approval letter Any relevant documentation to support medical necessity (chart or laboratory notes, letter of medical necessity, etc) Drug purchase invoice Some payors may also pp y ( request: 1. WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips. Accessed 11/25/

7 Medicaid - Billing Unclassified HCPCS Codes Physician Office Bill on the CMS-1500 or electronic equivalent Example HCPCS: J3590 or J3490 NDC is required on Medicaid claims including the paper CMS-1500, electronic 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 format of Example: would be reported as Centers for Medicare & Medicaid Ser ices (CMS) Transmittal 1401 cms go /transmittals/do nloads/r1401cp pdf 1. Centers for Medicare & Medicaid Services (CMS), Transmittal Accessed 06/03/ WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips. Accessed.:06/22/2010.

8 Private Payors - Billing Unclassified HCPCS Codes Physician Office Bill on the CMS-1500 or electronic equivalent. Example: J3590 Unclassified biologics J3490 Unclassified drugs Hospital Outpatient Bill on the UB-04/CMS-1450 or electronic equivalent. Example: J3590 Unclassified biologics J3490 Unclassified drugs Additional information required in Box 19 will vary by payor Additional information required in Field 80 (Remarks) will vary by payor Centers for Medicare and Medicaid Services, Transmittal 1924, February 26, Accessed November 24,2010.

9 EXAMPLE CLAIM FORMS

10 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 Box 21: Enter ICD-9-CM diagnosis code based on the patient s documented medical record Box 24 D: Enter CPT / HCPCS code(s) for procedure and other services provided XXX XX XXX XX J3490

11 Hospital Outpatient: Sample UB-04 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

12 Reasons for Claim Denial Common reasons include: 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 Incorrect modifier or lack of a modifier Service not deemed a medical necessity Insufficient information to process the claim (eg, missing NDC, prior authorization number, invalid NPI) Site of service mismatch 12

13 Billing correctly the first time may prevent a delay in processing your claim Provide appropriate documentation in the patient s medical record to justify the coding If submitting an unclassified/miscellaneous code, include additional information as required by the payor Verify yyour computer software is current and consistent with built-in edits Track clearinghouse claims to ensure successful transmission Monitor payor coding and coverage policies. 13