Oncology & Hematology Coding Alert

Question: I-ve been getting denials from Medicare for calcitonin injections provided incident-to the physician's service. Why?

Alaska Subscriber  Answer: Alaska Medicare-contractor Noridian's coverage rules exclude calcitonin (J0630, Injection, calcitonin-salmon, up to 400 units) from payment because it is usually self-administered by the beneficiary. The rule only applies to outpatient drugs in the outpatient setting.

Your oncologist may have ordered the calcitonin to help a patient with bone pain from metastasis.

Tip: You don't need an advance beneficiary notice (ABN) for this procedure because you will get a -benefit category- denial, rather than a medical-necessity denial. Benefit-category denials result when there is no benefit category covering the drug. You may charge the beneficiary for the drug. Good idea: You may not need an ABN but, as a courtesy, inform the patient of his financial responsibility before administering the calcitonin.