Wiki J3490 and injection denied

[patcpc]

Anyone getting denials for use of a non-FDA-approved drug AND the injection code, i.e. 20550? In the past they would deny the drug but pay the injection and we could bill the patient for the drug (ABN properly executed) but now they're denying the injection code also! Help!

 

[shekinahcpc]

It sounds like the payer is now saying that if the drug was not FDA approved then they do not support neither the drug or the administration. If you have an ABN on file I would bill the patient for the balance & use this experience as a learning lesson for future claims.

 

[shekinahcpc]

On second thought, I would probably try to either call the payor and/or appeal that administration denial to see what happens 1st. THEN if all that fails, I would bill the patient and consider it a lesson learned.

 

[mitchellde]

However if the ABN was only for the drug then you could not charge the patient for the administration. ABNs must very specific.

 

[dclark7]

You don't say what insurance this is, but Medicare policy states that "Services related to non-covered services or drugs are also not covered (e.g. adminitration services)."

 

[vpcats]

If the drug is not covered (aka, not medically necessary) then it wouldn't be medically necessary to administer it either. It seems like the payer is doing what they should have been doing.