Wiki J8540 vs J1100

[kookykk]

As a Pediatric office, we give oral dexamethasone for Croup. We have been billing J8540 for this since it was given orally and not injected, but recently a major payer is denying this code and leaving the charges to patient balance. One patient has stated the payer told her J8540 is an RX so it is not covered under their Medical Benefits. I cannot find definitive documentation to tell me if you can bill the J1100 when giving the Dexamethasone orally, rather than injecting. Does anyone know or have good documentation to support billing either way so we can make sure we are billing appropriately? Thank you.

 

[Cynthia Hughes]

I would not report code J1100 because the description includes injection. Code J8540 would be appropriate but may be denied as you noted because of payer policy. It may be beneficial to contact the payer directly to determine if the administration of oral medications in the physician practice is a reportable service (ie, you can bill for drugs administered orally). Many plans limit coverage of oral medications to those for chemotherapy and related anti-emetics. CPT code 99070 might also be used to report drugs and supplies provided by the physician.

 

[kookykk]

Thank you. I am glad to hear that someone agree's with what we are doing. I fully agree, payer's will have their own policies on coverage for that. I'll see if your suggestion of CPT is something our providers would like to use. Thanks again for taking the time to respond.