Practice Management Alert

Question: We provide injections and infusions in our office and seem to keep getting denials on the HCPCS drug supply charges we are billing out to payers. What might we be doing wrong?

Oregon Subscriber

Answer: Without knowing the denial code you are getting back, it is hard to say why you are seeing denials. Here are a few possible reasons, however:

When you submit a claim for drug payments, in many cases, it is now necessary to also include the full drug name, the total dosage or units administered, method of administration, and the National Drug Code (NDC) number on the claim form. If you are missing any of that information, you may see rejections for that reason.

You may be putting the wrong number of units in box 24G on the CMS-1500 form, or using the wrong administration code to go with the drug you are reporting.

Example: Your physician administers 4 mg IV Zometa over a period of more than 15 minutes. According to the code descriptor for Zometa (J3487, Injection, zoledronic acid [Zometa], 1 mg), you will report the 4 milligram dosage with the number 4 in column 24G of the CMS-1500 form indicating the 4 milligrams were given since the code is based on a 1 milligram does. Because the Zometa was administered by an infusion greater than 15 minutes, you would also use administration code 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to one hour).

Warning: If your provider has the patient pick up the drug somewhere else, such as a pharmacy, and bring it to your office, you cannot report the drug supply as your office has not incurred the cost of the drug. Just bill for the administration of the drug, and note in Box 19 of the 1500 form or its electronic equivalent the drug information noted above. Also note that the patient has supplied this drug for your administration.