J7328

PCMOS

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Anyone know what I cannot find J7328 (GelSyn) listed on the 4th quarter payment allowance limits for Medicare Part B Drugs? We are considering using it but want to verify reimbursement first.
 

klamond

Networker
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48
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Hamilton
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We had the same dilemma a while back so I reached out to the Gelsyn rep and she advised the following "The CPT code for Gelsyn3 will not be on the Medicare ASP drug pricing file until around April because it is a new product. Usually it takes a while for Medicare to determine an ASP. During the lunch, I showed the doctors +6 Examples of EOB's with Medicare due to the fact you would not be able to see it on the website.
Since it is a newer code there is no average sale price determined and it can take up to two quarters to a year to be listed on the ASP pricing file. Right now, Medicare bases the reimbursement on something called WAC (wholesale acquisition cost) which for this code its $345.00 plus 6 % which gives you the allowed amount of $366.00. " We have been billing it out and getting reimbursed from Medicare. Hope this helps
 

klamond

Networker
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48
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Hamilton
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We are also having an issue with comp. They are paying the code but way under the cost of what we pay for the medication stating the code is not in our contracts. We've also had denials for the dx since only osteoarthritis is covered so the carriers want it causally related to the comp injury. We have began to script it out and have the patient obtain the meds from the pharmacy and return for the injection until we can straighten it out.
 

ncalderon

Contributor
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Thanks for the input this helps. I have filed an appeal with WC and will keep you posted after I get reponse.
 
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