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