Modifier for Specialty Pharmacy Infusion Drugs

jennifercipriano

Contributor
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Pawtucket, RI
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Hi we have a list of drugs that have to be ordered through the patients specialty pharmacy therefore we cannot bill the drug to the insurance. Is there a modifier that we can put on the drug CPT so the insurance will know it was from a specialty pharmacy and not bought by us? We have been not billing the J(drug) code due to it being specialty. We do not need to be reimbursed for the drug just the time and administration. I have looks but cant seem to find anything. Thank you
 

thomas7331

True Blue
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There is no modifier I am aware for this situation. There is a modifier SL for state-supplied vaccines, but not for drugs.

The standard practice is to bill the drug HCPCS code with a zero dollar or one penny charge which identifies the administered drug for the payer but at the same time shows that no cost was incurred was incurred by the provider and no reimbursement is expected for the drug product itself.
 
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When Aetna mandates that an employee obtain their infusion medicines from the specialty pharmacy, how do you get the claim paid the first pass? When we bill the J code at $1 to support the admin codes, Aetna denied the J code and the admin codes for lack of authorization. Since the medicine is being obtained from the pharmacy, the authorization is on file with them. When we bill the admin code with no J code, thinking the pharmacy invoice will be tied to the date of service and it will all come out in the wash, it doesn't. We get denied for experimental. How do you get Aetna to successfully pay for an infusion claim with specialty medication the 1st time out? SB
 

mistyd2

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deberry, TX
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When Aetna mandates that an employee obtain their infusion medicines from the specialty pharmacy, how do you get the claim paid the first pass? When we bill the J code at $1 to support the admin codes, Aetna denied the J code and the admin codes for lack of authorization. Since the medicine is being obtained from the pharmacy, the authorization is on file with them. When we bill the admin code with no J code, thinking the pharmacy invoice will be tied to the date of service and it will all come out in the wash, it doesn't. We get denied for experimental. How do you get Aetna to successfully pay for an infusion claim with specialty medication the 1st time out? SB
When I bill meds from the pharmacy, I bill the code with one unit at 0.01. No modifiers are used. I never have a problem with them paying. Sometimes I attach the pharmacy PA but only if I have it.
 
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