Otolaryngology Coding Alert

You can still get paid for noncompounded solutions, but you-ll need to switch to Q codes

Before you bill Medicare for your next nebulizer treatment dose, you had better update your codes -- or risk nonpayment.

The first half of 2007 marks a major re-sweep of albuterol and levalbuterol codes. Here are five steps you can't afford to dodge -- and one FAQ that will help your future drug billing.

1. Report Noncom Solution With Q Code

For Medicare, you can forget the J codes for albuterol and levalbuterol that you just learned two short years ago. CMS is once again changing the HCPCS level-II codes associated with these drugs. Effective July 1, 2007, Medicare Part B carriers will no longer pay for J7611-J7614.

New way: You should now use a Q code when billing Medicare for inhalation solution that your practice purchases and provides for a nebulizer treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and for pre-/post-spirometry (94060, Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration).

The new Q codes include:

• Q4093 -- Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol)
• Q4094 -- Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol).

2. Set Up Red Flag for 4 J Codes

To avoid future Medicare claim denials for deleted codes J7611-J7614, mark the codes in your computer system as -invalid for Medicare as of 07/01/07.-

-Don't delete the codes,- which private payers may still accept, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. Designating the codes as invalid for Medicare prevents staff from accidentally assigning the codes to Medicare claims.

Great option: Alternatively, check to see if your software can provide a translation to the -Q- codes from the -J- codes within the practice management software for Medicare carriers, Cobuzzi says. -Some practice management software products carry tables that enable these translations depending on the payer.-

Codes for albuterol and levalbuterol that are nonpayable by Medicare include:

• J7611 -- Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg
• J7612 -- Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg
• J7613 -- Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg
• J7614 -- Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg.

3. Replace 4 Superbill Entries With 2

Although CMS doesn't swap one inhalation solution J code with one Q code, you can easily wrap your hands around the uneven change. When looking at the new Q codes, equate:

• - Q4093 with J7611 or J7612. Codes J7611-J7612 merge into one code for the concentrated form of albuterol (1 mg) or levalbuterol (0.5 mg).
• - Q4094 with J7613 or J7614. Codes J7613-J7614 merge into one code for the unit dose form of albuterol (1 mg) or levalbuterol (0.5 mg).

Time-saver: You can overlook the Q codes- lengthy descriptors and zoom in on one factor: the inhalation solution's form. The only difference between the new inhalation solution Q codes is that Q4093 is for the concentrated form and Q4094 is for unit dose.

To read about the HCPCS codes changes for albuterol and levalbuterol, see MLN Matters Number: MM5645, posted at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5645.pdf.

4. Advise Patient Before Mixing Product

Earlier this year, CMS issued a revised policy that denies coverage for compounded inhalation solutions on the basis that they are medically unnecessary. That policy change takes effect July 1. Because a compounded inhalation solution is not a Food and Drug Administration (FDA) approved product, CMS dropped coverage of all such drugs, according to Noridian (Part B for 17 states). (Find out more about the policy changes at https://www.noridianmedicare.com/dme/news/docs/2007/03_mar/policy_changes.html.)

Best bet: Before using a compounded solution -- one that is mixed, combined or altered for an individual -- make sure the physician cannot effectively provide the treatment with a noncompounded solution. -If not, provide the patient with information (risks of not pursuing treatment, benefit of following through with treatment, and the financial responsibility involved) so that he may make an informed choice to proceed with treatment,- says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

The patient does not have to sign an advance beneficiary notice (ABN) for services and items that are excluded from coverage. -ABNs are only required for covered services that are deemed -not medically necessary,- - Pohlig says. -Compounded solutions do not meet this latter description.-

Tip: You may use a Notice of Exclusions From Medicare Benefits (NEMB) to accomplish the above notification. Although Medicare does not require the form, using an NEMB is a good idea for patient information and service. Find the NEMB at www.cms.hhs.gov/BNI/11_FFSNEMBGeneral.asp.

Do this: Code compounded versions of J7525 (pentamidine), J7608 (acetylcysteine), J7631 (cromolyn), J7639 (dornase alpha) and Q4080 (iloprost) with J7699, says Noridian's coding guidelines for inhalation solutions (www.edssafeguardservices.eds-gov.com/admin/viewdoc.asp?fn=Nebulizers_-_Policy_Article_-_Effective_01-01-2007.pdf). Reserve the specific J codes for the FDA-approved product.

5. Look Up Drug Codes on ASP File

Believing in one common myth can spell disaster for your drug coding. When coders can't locate a J or Q code on the Medicare Physician Fee Schedule, they often think that Medicare doesn't pay for the drug.

Reality: CMS pays drugs using the Average Sales Price (ASP) file, not the Medicare Physician Fee Schedule. You can find a Medicare fee schedule for J codes at www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01a_2007aspfiles.asp#TopOfPage.

The July 2007 file lists a payment limit of $0.127 (per mg for albuterol and 0.5 mg for levalbuterol) for Q4093 and $0.525 (per unit dose) for Q4094. The January 2007 file listed payment limits of:

$0.071 for J7611 (per mg for albuterol)

$0.989 for J7612 (per 0.5 mg for levalbuterol)

$0.065 for J7613 (per mg for albuterol)

$1.391 for J7614 (per 0.5 mg for levalbuterol).

Caution: Do not use a HCPCS level-II code to bill for a drug, such as albuterol, when your practice receives it for free. For instance, if a pharmaceutical company provides free samples for your practice to use for inhalation therapy, you should not code for the supply because the practice bears no expense for supplying the drug.