Reader Question:
How to Get Reimbursed for Drugs that Lack Codes
Published on Mon Nov 01, 1999
There are times when most oncology practices come across a treatment, drug or supply item that is so new it has not yet been assigned a code. In such cases, the pro-viders should use a code that best resembles the procedure or use codes for unlisted procedures, drugs and supplies.
The disadvantage of the first route is that it can produce payment that is not adequate for the time and resources used during the procedure, or for the cost of the drugs or supplies used. On the other hand, using a code for unlisted items opens the door to denials and increased paperwork, not to mention audits and repayments later.
The emphasis on using existing codes for unclassified items is stressed by coding manuals as well. HCPCS, for example, instructs providers that the unclassified codes such as J9999 should be used only if a more specific code is unavailable. Used prudently, however, codes for unassigned items and procedures, such as CPT 96549 (unlisted chemotherapy procedure) and HCPCS J9999 (unclassified, antineoplastic drug), can yield payment that best reflects the resources used.
You want to supply an exact CPT code, says Daniel L. Johnson, director with Health Care Consultants of America, an Augusta, GA-based coding consulting firm, whose clients include oncology practices. Even though there are 9,000 CPT codes, you cant always find one that fits exactly. And even though payment may be difficult to get when you use unassigned codes, there are times when you have to.
Codes for Unclassified Oncology Drugs
J9999 - not otherwise classified chemotherapy drugs administered by other than oral route
J8999 - not otherwise classified chemotherapy drugs administered orally
J3490 - not otherwise classified supportive drugs administered by other than oral route
Q0181 - not otherwise classified oral anti-emetics
J8499 - not otherwise classified nonchemotherapeutic drugs
J7599 - not otherwise classified immunosuppressive drugs
Unassigned Codes Determined by Route
of Administration
Until a new chemotherapy drug is given a specific
J-code, its given a not otherwise classified code according to the route of administration:
1. Unclassified chemotherapy drugs, such as Herceptin, administered by other than oral means (intravenous, intramuscular, subcutaneous) are coded as J9999.
2. Unclassified oral chemotherapy drugs, such as Xeloda, are coded as J8999.
3. Unclassified supportive drugs, such as anti-emetic medications, are classified by route of administration.
Three Tasks Crucial to Getting Paid
When oncology practices must choose a code for an unassigned procedure or medical item, Johnson says, they often neglect to perform three tasks to ensure proper payment:
1. Get prior clarification from the insurer. Maximizing reimbursement with codes for unassigned items requires communication between the provider and payer prior to any new procedure or use of new drugs or [...]
