J Codes

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We have recently started to bill out for pain pump refills and I'm not familiar with J codes. Right now for one specific patient we are needing to bill out for Bupivacaine PF 10MG/ML and Hydromorphone PF 1MG/ ML. I have been told by Iowa Medicaid, which is the insurance the patient has, that J3490 is a dump code, billable with documentation. I have also been advised to use J7799, also a dump code, billable with documentation. I'm not sure which direction to go in. If any one has any knowledge of what direction to go in for pain pump refills I would greatly appreciate it.
 

dwaldman

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https://www.dmepdac.com/crosswalk/index.html

I would look at the above NDC to HCPCS crosswalk files they have, which can be helpful if you are reviewing NDCs.

J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG HYDROMORPHONE HCL

J3490 UNCLASSIFIED DRUGS BUPIVACAINE HCL


For a pain pump refill, you need to review the number of ml of the refill such as 20ml or larger 40ml. Then review per ml how many mgs of the hydromorphone they are using versus just 1mg (how many mgs per ml). For example, for J1170 that the code descriptor is for up to 4mgs, you could have 9mg per ml in a 20 ml volume would be (9 x20) / 4 = 45 units.

The bupivacaine would fall under J3490, but for both this and the hydromorphone this is assuming these are off the shelf drugs and not compounded medications.

For 2016, there is a new J code for compounded drugs that purchased for intrathecal pain pump refill. Carriers can have different instructions on how they require these to be processed with specific instructions that can vary per carrier and the instructions were written prior to J7999 and refer to certain modifiers and other J codes or HCPCS codes.

Below is from the Medicare Internet-Only-Manual, which describes using a specific code when it is known the drug(s) is compounded

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf


Medicare Claims Processing Manual Chapter 17 - Drugs and Biologicals Table of Contents (Rev. 3340, 08-21-15)

20.1.2 - Average Sales Price (ASP) Payment Methodology (Rev. 3292, Issued: 07-10-15, Effective: 07-01-15, Implementation: 07-06-15) Section 303(c) of the Medicare Modernization Act of 2003 (MMA) revised the payment methodology for Part B covered drugs and biologicals that are not priced on a cost or prospective payment basis. Per the MMA, beginning January 1, 2005, the vast majority of drugs and biologicals not priced on a cost or prospective payment basis will be priced based on the average sales price (ASP) methodology. Pricing for compounded drugs is performed by the local contractor. Beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) HCPCS code. Beginning in 2006, all ESRD drugs furnished by both independent and hospitalbased ESRD facilities, as well as specified covered outpatient drugs, and drugs and biologicals with pass-through status under the Outpatient Prospective Payment System (OPPS), will be priced based on the ASP methodology. The ASP methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP drug pricing files for Medicare Part B drugs on a quarterly basis. Contractors

will be notified of the availability of this file via a Recurring Update Notification. Visit http://www.cms.gov/Medicare/Medicar...ndex.html?redirect=/McrPartBDrugAvgSalesPrice for more information about the ASP payment methodology.
Compounded drug, not otherwise classified
 
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