Wiki 96416, J9190, 96411 and Humana

[mellison710@gmail.com]

My office bills 96416, J9190 and 96411 (in that order) regularly. Humana consistently denies the 96411 (among many other things). This is not a problem with any other insurer that we bill to. can any one help me understand what we need to do differently with Humana?

 

[mhaleyw2brats]

96411 is billed when an additional chemo drug is infused 15min or less. How long is the J9190 infused for in the office? If 15 min or less I would bill 96409 and 96416 if sent home with a pump that infuses more than 8 hours of J9190and attach a modifier 59 to 96416.

 

[lillianivy]

We have the same problem with 5FU. Our Office manager is in the process of fighting it with our Humana rep. We usually give it on the same day with other drugs which is why we use the 96411 w/ mod 59. They are going back and recouping everything. It's crazy. They are the only insurance that does this. From what we have been told it's because they don't want you billing 2 separate administration codes for the same drug even though it was given 2 separate ways. Yet we have been taught that if it's administered in 2 separated ways then it is billable. I've done research and asked several other coders and we are coding it correctly. Humana is just being difficult. Of course, it's one of the many battles we have with that insurance. They are the worst. We have even had meetings in regards to no longer accepting that insurance. Try your Humana rep. Let them know you are coding and billing correctly. If y'all get a solution and start getting paid let me know.

jasonandlydia48@hotmail.com

Thanks,
Lydia

 

[Cynthia Hughes]

The parenthetic instruction under code 96411 limits its use to that with 96409 and 96413 but private payers may incorporate other policies which could cause automatic denial based on claims edits. I don't know of any guidance specific to this question but it is often helpful in negotiating with payers to have an answer to questions presented with specific billing scenarios answered by the AMA or other organizations to which your physicians belong (eg, ASCO, http://www.asco.org/billing-and-coding).