Question UHC Toradol (CPT J1885) Injection Denial

mistypace

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Our office is suddenly having denials from UHC for Toradol stating it needs a modifier. UHC is only denying the J1885. This is something that has just recently started happening. When we call UHC they just state it needs a modifier and to talk to the coder which is me. Has anyone else had this issue?
 

SharonCollachi

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Are you billing for inpatient, outpatient, facility, provider...?? How are you billing (how many units, what is the drug strength, what ndc code, etc.)?
 

mistypace

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Are you billing for inpatient, outpatient, facility, provider...?? How are you billing (how many units, what is the drug strength, what ndc code, etc.)?

Thank you for your reply!

I work in an outpatient urgent care facility. I am billing J1885 (15mg) x4. The NDC number is 00409379601. I would have to check with our nurses about the strength. I haven't seen any other insurance company have this denial especially for only the medicine.
 

SharonCollachi

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Yeah, I'm not getting it either. That is the NDC number for the standard 60mg/2ml single dose vial. We bill it the same way you do (provider's office). You did bill an injection code with it, right?

I have had to appeal a couple of medications where I photocopied the box it came in showing the NDC number because they were saying it was a discontinued NDC number, and it wasn't.
 

thomas7331

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Does your facility participate in a 340B drug discount program? If so, you may need to be reporting an appropriate modifier to indicate this.
 

mistypace

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Yeah, I'm not getting it either. That is the NDC number for the standard 60mg/2ml single dose vial. We bill it the same way you do (provider's office). You did bill an injection code with it, right?

I have had to appeal a couple of medications where I photocopied the box it came in showing the NDC number because they were saying it was a discontinued NDC number, and it wasn't.

Yes I am billing the 96372 injection code with it. We have been billing this way since I started here 4 years ago. It was just recently (about the last 2-3 weeks) that UHC is denying Toradol stating it needs a modifier. When we have an encounter with a Toradol injection we bill for that injection, the injection code and Modifier 25 on the OV. So I am not sure what I am missing or what step we should take next. Surely they aren't wanting a Modifier 59 on the Toradol.
 

mistypace

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Does your facility participate in a 340B drug discount program? If so, you may need to be reporting an appropriate modifier to indicate this.

No we do not participate in that program. ALL other insurance companies pay for this injection the way we are billing it. The only one we are having an issue with is UHC which includes GEHA UHC and UMR.
 

vgriffin

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Our office is suddenly having denials from UHC for Toradol stating it needs a modifier. UHC is only denying the J1885. This is something that has just recently started happening. When we call UHC they just state it needs a modifier and to talk to the coder which is me. Has anyone else had this issue?
I am getting the same denials as well. I got a letter from UHC denying my appeal stating it is part of the "Supply Policy", so I looked it up. Here is the link. It appears there are many drugs now bundled with the E/M visit. I am in Central Ca.

https://www.uhcprovider.com/en/poli...eimbursement-policies/COMM-Supply-Policy.html
 

thomas7331

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I am getting the same denials as well. I got a letter from UHC denying my appeal stating it is part of the "Supply Policy", so I looked it up. Here is the link. It appears there are many drugs now bundled with the E/M visit. I am in Central Ca.

https://www.uhcprovider.com/en/poli...eimbursement-policies/COMM-Supply-Policy.html

Per my reading of this policy, there are no drugs on the supply list that applies to an office setting - the drugs are only bundled for facility locations paid under the PPS and billed with place of service codes 19, 21, 22, 23 and 24. In an office setting, cost of drugs has never been incorporated into E&M code reimbursement for any payer that I've ever encountered. And also I don't think they would deny for a missing modifier if this was the case.

If I were in your place, I would try to get hold of a claims supervisor or network representative and try to get a clearer explanation of why these are being denied. In my experience, phone reps and appeals letters are notoriously unreliable as a source of accurate information about denials.
 

vgriffin

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Per my reading of this policy, there are no drugs on the supply list that applies to an office setting - the drugs are only bundled for facility locations paid under the PPS and billed with place of service codes 19, 21, 22, 23 and 24. And I don't think they would deny for a missing modifier if this was the case.

If I were in your place, I would get hold of a claims supervisor or network representative and try to get a clearer explanation of why these are being denied. In my experience, phone reps and appeals letters are notoriously unreliable as a source of accurate information about denials.
I thought the same thing at first, but then if you put J3 in the Policy Code box it drops down a list of drug codes. I went to the the other PDF on the same page and it has no J codes listed. There is an article for the POS 11, I was sure that was the link that I used. this link has the more information, but I am unable to open the documents in the article. I am a little confused by this, so any input would be greatly appreciated.


 

thomas7331

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I thought the same thing at first, but then if you put J3 in the Policy Code box it drops down a list of drug codes. I went to the the other PDF on the same page and it has no J codes listed. There is an article for the POS 11, I was sure that was the link that I used. this link has the more information, but I am unable to open the documents in the article.


The policy code box only tells you that the code(s) you've entered are referenced somewhere in the policy - it doesn't necessarily mean that it applies to your particular situation. Your first link is for UHC commercial plans and your second is for the UHC Medicaid plans. I'm able to open the attachments on both policies - they appear to both be the same - and there are no drug codes on the list that applies to office services.

If you're billing this from an office, I think you've been given incorrect information if they're telling you this policy is the reason behind the denials. I would push back on this if it is a significant dollar impact to your practice. This appears to be a new policy change, and it's quite possible that the claims system was programmed incorrectly when it was deployed and is causing denials that aren't backed up by the policy language. This should be escalated and they need to hear about this from the providers.
 

mistypace

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I spoke with the rapid resolution department at UHC this morning. I questioned the way they were handling the denial. The lady I spoke with was very nice and walked me through the website to see the link I needed for more information. She showed me that there are certain POS that can't bill supplies separately. At the begining of the policy it shows our POS (11) is included in the policy for not being able to charge J1885 as a seperate supply. Upon further reading while helping me she realized the rest of the policy reads that POS 11 is not included in this type of denial. She is going to the people over her to research it and get back to me. So it looks like a glitch or discrepency on their end.
 

vgriffin

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The policy code box only tells you that the code(s) you've entered are referenced somewhere in the policy - it doesn't necessarily mean that it applies to your particular situation. Your first link is for UHC commercial plans and your second is for the UHC Medicaid plans. I'm able to open the attachments on both policies - they appear to both be the same - and there are no drug codes on the list that applies to office services.

If you're billing this from an office, I think you've been given incorrect information if they're telling you this policy is the reason behind the denials. I would push back on this if it is a significant dollar impact to your practice. This appears to be a new policy change, and it's quite possible that the claims system was programmed incorrectly when it was deployed and is causing denials that aren't backed up by the policy language. This should be escalated and they need to hear about this from the providers.
Thank you. I appreciate your clarification on this matter.
 

vgriffin

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I spoke with the rapid resolution department at UHC this morning. I questioned the way they were handling the denial. The lady I spoke with was very nice and walked me through the website to see the link I needed for more information. She showed me that there are certain POS that can't bill supplies separately. At the begining of the policy it shows our POS (11) is included in the policy for not being able to charge J1885 as a seperate supply. Upon further reading while helping me she realized the rest of the policy reads that POS 11 is not included in this type of denial. She is going to the people over her to research it and get back to me. So it looks like a glitch or discrepency on their end.
Can you share the link that you used to find this policy. Thanks.
 

SharonCollachi

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I spoke with the rapid resolution department at UHC this morning. I questioned the way they were handling the denial. The lady I spoke with was very nice and walked me through the website to see the link I needed for more information. She showed me that there are certain POS that can't bill supplies separately. At the begining of the policy it shows our POS (11) is included in the policy for not being able to charge J1885 as a seperate supply. Upon further reading while helping me she realized the rest of the policy reads that POS 11 is not included in this type of denial. She is going to the people over her to research it and get back to me. So it looks like a glitch or discrepency on their end.

Please keep us informed as to the outcome. I am in Central California also, and the only reason I haven't billed the very same thing you have is that my doc has been out with COVID for 3 weeks now. He is returning to work tomorrow.
 

mistypace

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I was having trouble getting the link to show the denial codes. I had UHC fax a list of the codes that would be denied and saved it to my computer. Below are the pdf's for the Supply Policy and the supply denial codes that I saved. Please let me know if they will not work so I can reload them. I am still waiting to hear back from UHC on this matter.
 

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  • UHC Supply Denial Codes.pdf
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SharonCollachi

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At the begining of the policy it shows our POS (11) is included in the policy for not being able to charge J1885 as a seperate supply. Upon further reading while helping me she realized the rest of the policy reads that POS 11 is not included in this type of denial.

Can you point out where in the policy this was? I see a "List of HCPCS supply codes not separately reimbursable in an office..." and then an attachment, is that the attachment you have above?
 

mistypace

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Sure. In the first PDF labeled Supply Policy, the bottom of pg. 1 and the top of pg.2 states:

Reimbursement GuidelinesSupply Reimbursementin a Physician’s or Other Qualified HealthCare Professional’s Officeand Other Nonfacility Places of ServiceCertain HCPCS supply codes are not separately reimbursable as the cost of supplies is incorporated into the Evaluation and Management (E/M)service or procedure code. UnitedHealthcare will not separately reimburse the

Commercial Reimbursement Policy CMS 1500Policy Number 2020R0006HProprietary information of UnitedHealthcare. Copyright 2020UnitedHealthCare Services, Inc.HCPCS supply codes when those supplies are provided on the same day as an E/M service and/or procedure performed in a nonfacility place of service by a physician or other qualified health care professional.For the purposes of this policy, a nonfacility place of service is considered POS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81 and 99.


Then the bottom of pg. 2 (above Supply Facility J-Code Denial List link) states:

Consistent with CMS, UnitedHealthcare will not allow separate reimbursement for specific HCPCS supplies, DME, orthotics, prosthetics, biologicals, and drugs when submitted on a CMS-1500 claim formby any physician or other qualified healthcare professionalinthe following facility POS:19, 21, 22, 23, and 24.The UnitedHealthcare Supply Facility J-Code Denial Code list and Supply DME Codes in a Facility Setting contains the codes that are not separately reimbursable in a facility place of service.

The pdf labeled Supply Denial Codes is the full list of J-codes that will be denied.

Let me know if this helps!
 

mistypace

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****UPDATE****
I spoke with UHC again today. They have had numerous calls about this issue. They have updated the policy and removed J1885 from the denial list for POS 11 (office setting). (Policy PDF attached) Unfortunately from what I understood they will not reprocess the claims previously denied for the following reasons: 1. If claim is resubmitted it will be denied as duplicate claim. 2. If asked to reprocess it will be denied stating the processing was correct according to the policy at this time.

I spoke with our billing supervisor and she may call to follow up and verify the reprocessing issue. Thank you to everyone for your input and I hope this helps.
 

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ncolbert

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Yes my clinics are receiving the same denial.. matter of fact one of my collectors just brought this up on yesterday so I began researching. I notice in the top half of the policy it states that non-facility place of service is considered POS 1, 3, 4, 9, 11, 13, 14, 15, 16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81 and 99

But when you open the document for the supply facility J-Code list (see attached screenshot) POS 11 is not listed as ones of the places. Their policy states: A list of HCPCS drug codes not separately reimbursable in POS 19, 21, 22, 23 and 24.

So even your denial I believe is not valid because it doesn't list POS 11 either for your J code (J1885).

We were billing J1100 with POS 11. I will have my collector call back to see about having them reprocessed because this seems to be a error on their part.
 

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houmaob1714

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****UPDATE****
I spoke with UHC again today. They have had numerous calls about this issue. They have updated the policy and removed J1885 from the denial list for POS 11 (office setting). (Policy PDF attached) Unfortunately from what I understood they will not reprocess the claims previously denied for the following reasons: 1. If claim is resubmitted it will be denied as duplicate claim. 2. If asked to reprocess it will be denied stating the processing was correct according to the policy at this time.

I spoke with our billing supervisor and she may call to follow up and verify the reprocessing issue. Thank you to everyone for your input and I hope this helps.
Was your billing supervisor able to get an update on how they will reprocess the claims?
 

trarut

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****UPDATE****
I spoke with UHC again today. They have had numerous calls about this issue. They have updated the policy and removed J1885 from the denial list for POS 11 (office setting). (Policy PDF attached) Unfortunately from what I understood they will not reprocess the claims previously denied for the following reasons: 1. If claim is resubmitted it will be denied as duplicate claim. 2. If asked to reprocess it will be denied stating the processing was correct according to the policy at this time.

I spoke with our billing supervisor and she may call to follow up and verify the reprocessing issue. Thank you to everyone for your input and I hope this helps.
We were having the same issue with a different medication and were told the same thing - they will not reprocess. Thankfully, it is a low cost medication for us so we're not going to be eating a huge amount of money. I'm not entirely sure how they can get away with making an error in their policy and not backdating the correction but I guess that's why I work for physicians and not an insurance company.
 

mistypace

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Was your billing supervisor able to get an update on how they will reprocess the claims?
We were not able to get it reprocessed. I don't see how they are not going to reprocess. I asked about refiling as a corrected claim and they stated it would still deny because at that time the policy was correct and the denial was correct according to the policy at that time.
 
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