Wiki oncology billing concern

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ocorpuz

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Does anyone having trouble getting paid by medicare for herceptin J9355, we are trying to bill this to medicare since february and everytime we submit claims it gets denied.
Also for kyprolis(J9999) for medicaid? I live in va.

any help how to bill this I will greatly appreciated...
 
J9355 allows 100 units so if you bill over 100 like we do then you need to challenge it. the dose is based on patients weight etc etcv. you may need the dr to write something up.
 
ocorpuz said:
Does anyone having trouble getting paid by medicare for herceptin J9355, we are trying to bill this to medicare since february and everytime we submit claims it gets denied.
Also for kyprolis(J9999) for medicaid? I live in va.

any help how to bill this I will greatly appreciated...
Click to expand...

First what does the denial state?
second what dx code did you use and what other CPT codes did you use?
 
Debra is correct, there is no way to answer this without knowing what the denial says, what diagnosis code you are using and the CPT codes you are using. Is it being billed with any other drugs or infusions? Are you using V58.12 as the 1st diagnosis code? How many units was the patient given and how many are you billing?

Kyprolis is coded as J9999 and comes in a single dose vial of 60 mgs and the drug name and NDC # should be on the claim. How many units are you billing?
 
I live in CA and we have to put a formula in line 19 of the claim form in order to get both Herceptin and Kyprolis paid. The Herceptin formula is:
Dose in MG/Kg x weight in KG = __mg divided by 10 = ___ correct dose
it is written very specifically "__mg/kgX__kg=__mg/10mg(1UOS)=__(UOS)"

Heather O'Leary, CPC, CHONC
 
I would suggest reviewing the number of units billed for the medication itself. This is a huge issue with Herceptin as you can not bill wastage because it is a SDV (single dose vial).
Kimberly Farley, CPC, CPC-H, CHONC
 
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