Wiki Compounded Drugs

[CCMB]

I am in need of some guidance on billing multiple drugs for an infusion pump.
Example of how we do it now for Medicare: Under "description" ~ J7999 =
CMP DILAUDID 840 MG SUFENTANIL 235200 MCG KETAMINE 50400 MCG BUPIVACAINE 504 MG, this gets denied for many different reasons.

Example of how we bill for commercial is attached:


Any guidance is greatly appreciated. These drugs are supplied by the pharmacy to us in one syringe and are used in a patients intrathecal pump.

 

[SharonCollachi]

I am assuming this is in an office and not in an outpatient hospital setting.

Units of J7999 is always one.

Is it compounded or is it multiple drugs? (You're billing commercial as multiple, but billing Medicare as compounded???) Medicare states, "Compounded drugs created by a pharmacist in accordance with the Federal Food, Drug and Cosmetic Act and the FDA Modernization Act of 1997 may be covered under Medicare when their use meets all other criteria for services incident to a physician's service. Compounded drugs do not have a National Drug Code number (NDC). Mixing two or more pre-packaged products in the same syringe when prepared according to label instructions, does not meet the definition of a compounded drug. Compounded drugs are used to meet the special needs of a patient. Examples of when a compounded drug is used include, but are not limited to the following:

• Patient is allergic to an inactive ingredient in off-the-shelf drug and a compound is made omitting that ingredient
• Dosage strength required is not available when prepared according to label instructions. (For drugs requiring reconstitution, this means after drug has been reconstituted per label instructions.) For example, a drug used in an infusion pump or reservoir may require compounding.

If any part of the mixture is off-the-shelf, then that is listed separately from the part that is compounded, otherwise everything will deny.

You said you put the list under "description", but I don't know where that is going on the HCFA. It should be box 19.

According to the latest price list I have, which may be low, your expected reimbursement is:
Dilaudid 840 x $0.13= $109.20
Sufentanil 235200 x $0.09 = $21,168.00 <-- that's over a gallon (I'm only showing 50 mcg/ml), are you sure that's correct? (50mcg per ml = 4704 mls = 1.24 gallons)
Ketamine 50400 x $0.0048 = $241.92
Bupivicaine 504 x $0.04 = $20.16

TOTAL = $21,539.28
Compound fee = $60.00
Grand total = $21,599.28

So it could be that the total volume is incorrect, it could be that you're filling more frequently than you should be, it could be that you're using medications that aren't actually compounded, it could be that your diagnosis is incorrect, etc.

What are the specific denials that you're getting?

 

[CCMB]

Hi Sharon,
Thank you so much for responding. These are compounded drugs from the pharmacy and are for infusion pumps. As for billing commercial one thing and Medicare another, that is where we are needing guidance. These carriers are wanting different things and this is causing confusion.
Medicare just cannot seem to get on the same page. We just had a supervisor tell me yesterday that everything we have billed is correct and she was personally going to the review department.
Some of the drugs have their own HCPCs codes, and most of the commercial carriers keep denying as an injection. We keep having to appeal and point out that these are for an infused pump.
We are just looking for guidance on how to get these paid the first time out.

 

[SharonCollachi]

I'm still not convinced these are actually COMPOUNDED versus just put in one syringe. It does look like some of them should be on a separate line item. And it does look like the quantities you have are more than either a syringe or the pump can hold. For instance, how many micrograms per ml is the supplied Sufentanil?

If you bill the pump refill with the meds, you should not be getting denials for the meds being for injection instead of pump. If you have a commercial that is not recognizing the KD modifier, that's a different story.

Again, what are the specific denials? What are the dx? What CPTs were billed for the procedures? What is the POS? Is there a referring doctor on the claim (even if it's the doctor who did the work himself)?

It's hard to pinpoint the issues without all of the information.