Pediatric Coding Alert

Question: We are receiving denials for CPT code J7610. Should we be billing a different code for Albuterol Inhalation Solution Compounded Product 1mg?

Georgia Subscriber

Answer: Code J7610 (Albuterol, inhalation solution, compounded product, administered through DME, concentrated form, 1 mg) is still an active code, but Medicare changed the code's status on the Physician Fee Schedule, which means that private payers may also be following the same value change. The code's status is E, which stands for "Excluded from Physician Fee Schedule by regulation...No RVUs are shown, and no payment may be made under the fee schedule for these codes. Payment for them, when covered, generally continues under reasonable charge procedures."

What that means is that any payers that follow Medicare's fee schedule may have stopped reimbursing for this code. Ask your insurer for details on its current coverage guidelines for this code. You should ask your patient to sign an advance beneficiary notice (ABN) in case you don't collect for this service.

In response to your question about whether you should bill a different code, the answer is most likely no. If J7610 best describes the product that your physician provided, then you should not simply choose a different code to optimize your payment. Code correctly, then appeal if you feel your claim has been wrongly denied.