Pain Pump Refills

lcole7465

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Toledo, OH
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So every time I think we've got the billing for the pain pump refill medications figured out, we start getting denials. The latest denial I received was from Medicare that the CPT/HCPCS were billed incorrectly for compound drugs. I billed as J3490-KD.

The drug combination is: Fentanyl Citrate Powder 8mg; Bupivicaine 200mg; Sodium Chloride 40ml; Sterile Water20ml

Thanks in advance for any help.
 

SharonCollachi

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You should be using J7999. Noridian Medicare (just the first one I happened to pull up, click me for the full document)says:

Compounded Drugs Billing

Compounded drugs created by a pharmacist in accordance with the Federal Food, Drug and Cosmetic Act and the FDA Modernization Act of 1997 may be covered under Medicare when their use meets all other criteria for services incident to a physician's service. Compounded drugs do not have a National Drug Code number (NDC).

Mixing two or more pre-packaged products in the same syringe when prepared according to label instructions, does not meet the definition of a compounded drug.

Compounded drugs are used to meet the special needs of a patient. Examples of when a compounded drug is used include, but are not limited to the following:
  • Patient is allergic to an inactive ingredient in off-the-shelf drug and a compound is made omitting that ingredient
  • Dosage strength required is not available when prepared according to label instructions. (For drugs requiring reconstitution, this means after drug has been reconstituted per label instructions.) For example, a drug used in an infusion pump or reservoir may require compounding
Since the compounded medications do not have an NDC, specific HCPCS J-codes cannot be used. Instead, providers should bill J3490 (unclassified drugs); J3590 (unclassified biologics); J7999 (compounded drug, not Oral) or J9999 (Not Otherwise Classified (NOC), antineoplastic drug).

When billing for a compounded drug, the information must be put into item 19 of the CMS-1500 paper claim form or the electronic equivalent. Providers should indicate the drug is compounded and include the drug name and total dosage given for each drug.

Narrative Example

  • Bill JXXXX for one (1) unit of service
  • Include compound verbiage or abbreviation (CMP) to indicate a compounded drug
  • Drug name(s) and dosage(s)
  • Route administration if multiple routes

If any of the required information is not submitted, it will be denied as unprocessable. Noridian does not reimburse separately for a compounding fee.
 
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