Part B Insider (Multispecialty) Coding Alert

Published on Sat Oct 30, 2004 PDF

Don't forget crucial information when billing for new MDS drug

A new therapy offers hope to many of your patients with myelodysplastic syndromes (MDS) - but only if you can master the intricacies of billing for a drug that lacks its own code.

The Food & Drug Administration approved Vidaza on May 19, and providers started billing it over the summer. After a slow start, carriers have started to recognize the drug and pay claims, providers say. One carrier, Cahaba GBA, included a notice in its latest bulletin stating Cahaba would pay for Vidaza as long as providers followed the FDA criteria.

How to get paid: Bill unlisted code J9999 and include the name and dosage of the drug in block 19 of the paper claim, or in the description field of electronic claims, Cahaba instructed. Medicare will reimburse $452.50 for a 100 mg. dose of Vidaza. The claim must also include ICD-9 codes that indicate FDA-approved diagnoses.

When billing Medicare carriers for Vidaza, you must mark the name of the drug instead of the NDC code. But conversely, when billing non-Medicare payors, you need to mark the NDC and not the drug name, notes Nancy Giacomozzi, office manager for medical billing agency P.K. Administrative Services in Lakewood, CO.

Usually, you should use ICD-9 code 238.7, for myelodysplastic syndromes, with claims for Vidaza, notes Mary Fico, a coder with Oncology Hematology Associates in Bradenton, FL.

Fico received some denials for Vidaza at first because the carriers hadn't updated their systems to include the drug. Several patients started using Vidaza at once, and the carrier denied all their claims in the first week. But the carrier eventually fixed the problem and now Fico's practice is receiving payments without any problem, she reports.
 
Appeal Letter Should Include List Of Other Therapies

If your carrier denies claims for Vidaza, then manufacturer Pharmion says an appeal letter should include the patient's history and a list of other therapies you tried, including any significant complications if appropriate.

Currently, Vidaza is the only FDA-approved drug for MDS, which are bone marrow disorders in which blood cells function abnormally. Before Vidaza, drugs only treated the symptoms of MDS, notes Giacomozzi.