I have been billing for a Hematology/Oncology group for about 6 years. I have 1 payer that has recently changed their edits and is causing me significant grief. So far my appeals have been denied. Here is what's happening:
On day 1 of folfox, we bill:
J1100 (over 30min)
J2405 (over 30min)
J0640 (over 2 hrs concurrently with J9263 in separate bags w Y connector)
J9263 (over 2 hrs)
J9190 (part of dose given as a push and part given via portable pump)
Admin codes billed are: 96367x2, 96368, 96413, 96415, 96411 (5FU push), 96416 (5FU in portable pump infused over 22 hrs)
On day 2 of folfox, we bill:
J1100 (over 30min)
J2405 (over 30min)
J0640 (over 2 hrs)
J9190 (part of dose given as a push and part given via portable pump - same as on day 1)
Admin codes billed are: 96367x3, 96366, 96409, 96521 (for the refilling of the portable pump w 5FU)
Day 1 is paid without any trouble and all of Day 2 is paid except for the 96409 and 96521. Only one code gets paid (and it varies which code they decide to pay).
I got a pretty decent description of their logic on one of the responses to my appeal. (Usually I just get a letter stating that they are upholding their denail without any explanation.) "Our Medical Review Staff has approved CPT Code 96521 on this claim but denied CPT code 96409 because, according to the submitted records, 5FU was given by IV push bolus in conjuction with a prolonged continuous infusion by pump of the same drug. In this scenario (bolus/pump), we recommend payment for only on emethod for the 5FU administration. The Medical Review STaff determind to allow payment for the higher valued CPT code 96521 and to deny CPT code 96409. The claim has been reprocessed ..."
So they are now denying the 96409 which is the initial code required for payment of all the 963** infusion codes. 96521 is not an initial code. So, there is now no initial code paid for this DOS.
And they don't seem to have an issue with Day 1 96411 and 96416 both admin codes for 5FU.
My understanding has always been that because the 2 doses are given by different methods that they were both payable. This has been supported by the fact that I have never seen a problem with ANY other payers (including Medicare and we deal with several different medicare contractors). Am I wrong? Are they all wrong?
Whew! This turned into a long post. I appreciate any thoughts any of you all have!
Alanna
On day 1 of folfox, we bill:
J1100 (over 30min)
J2405 (over 30min)
J0640 (over 2 hrs concurrently with J9263 in separate bags w Y connector)
J9263 (over 2 hrs)
J9190 (part of dose given as a push and part given via portable pump)
Admin codes billed are: 96367x2, 96368, 96413, 96415, 96411 (5FU push), 96416 (5FU in portable pump infused over 22 hrs)
On day 2 of folfox, we bill:
J1100 (over 30min)
J2405 (over 30min)
J0640 (over 2 hrs)
J9190 (part of dose given as a push and part given via portable pump - same as on day 1)
Admin codes billed are: 96367x3, 96366, 96409, 96521 (for the refilling of the portable pump w 5FU)
Day 1 is paid without any trouble and all of Day 2 is paid except for the 96409 and 96521. Only one code gets paid (and it varies which code they decide to pay).
I got a pretty decent description of their logic on one of the responses to my appeal. (Usually I just get a letter stating that they are upholding their denail without any explanation.) "Our Medical Review Staff has approved CPT Code 96521 on this claim but denied CPT code 96409 because, according to the submitted records, 5FU was given by IV push bolus in conjuction with a prolonged continuous infusion by pump of the same drug. In this scenario (bolus/pump), we recommend payment for only on emethod for the 5FU administration. The Medical Review STaff determind to allow payment for the higher valued CPT code 96521 and to deny CPT code 96409. The claim has been reprocessed ..."
So they are now denying the 96409 which is the initial code required for payment of all the 963** infusion codes. 96521 is not an initial code. So, there is now no initial code paid for this DOS.
And they don't seem to have an issue with Day 1 96411 and 96416 both admin codes for 5FU.
My understanding has always been that because the 2 doses are given by different methods that they were both payable. This has been supported by the fact that I have never seen a problem with ANY other payers (including Medicare and we deal with several different medicare contractors). Am I wrong? Are they all wrong?
Whew! This turned into a long post. I appreciate any thoughts any of you all have!
Alanna