Wiki Medicare denial Benlysta

lcole7465

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We have been getting denials from Medicare for this drug, HCPCS code J0490 - as not covered when self administered. The office manager keeps insisting on adding modifier -JA to the code to get it paid. I don't see that it qualifies for this modifier as this is given intravenously and not subcutaneously, but I am seeing that this can be self administered by the patient. Should the modifier -JA be added to this claim for this reason?

Thank you
 
My experience is that drug designated as self-administered are always non-covered. I don't think that the modifier will get this paid for you, and it's not listed as one of the drugs to which this modifier applies in the Medicare policy:
Billing and Coding: Complex Drug Administration Coding
The med is not being self administered, it is being administered via IV-infusion. I believe the claim should just need to be appealed with the office notes showing this was not self-administered by the patient but by infusion by the provider.

Thank you
 
The med is not being self administered, it is being administered via IV-infusion. I believe the claim should just need to be appealed with the office notes showing this was not self-administered by the patient but by infusion by the provider.

Thank you
I understand what you're saying, and it may be worth trying an appeal, but I still don't believe Medicare will pay for it. When hospitals bill for insulin given to patients during an outpatient encounter, for example, these are always denied because it is considered a self-administered medication. It does not matter that it was administered by a nurse in the facility - it is still a non-covered item under Part B.
 
We have been getting denials from Medicare for this drug, HCPCS code J0490 - as not covered when self administered. The office manager keeps insisting on adding modifier -JA to the code to get it paid. I don't see that it qualifies for this modifier as this is given intravenously and not subcutaneously, but I am seeing that this can be self administered by the patient. Should the modifier -JA be added to this claim for this reason?

Thank you
For Benlysta and Orencia, Medicare requires modifier JA if it was done by infusion.
 
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