Wiki Zilretta Billing

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GCLindsay

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Pleasant Grove, Alabama
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Hey, guys!

We will soon start using Zilretta in our office but have run into a big of a puzzle. We were told to bill it under CPT J3490, Unclassified Drugs, and to put the information about the drug in box 19. In the past, we have not had any luck with this code and many of the larger payers will reject or deny the charge line. Has anyone tested this for Zilretta?
 
Submitting a description in box 19 is generally not sufficient any more for payers, especially when you're using an unlisted code such as J3490. To ensure the payer has the complete information they need for processing, you should submit the full NDC, units of measure, and quantity administered in the required formats. On a paper claim form, this would go in box 24 in the red shaded area, or on an electronic claim form in loop 2410. Your billing software vendor should be able to help you get this information into the right place and format, and your payers should have detailed information available as to how they need this information in order to get correct payment.

Here a good document of instructions from BCBS of TX, which is the standard way most payers handle this information now. If you follow this, you shouldn't have too many trouble getting these claims processed correctly:

https://www.bcbstx.com/provider/pdf/ndc_faqs.pdf
 
New HCPCS code for Zilretta coming in July

GCLindsay said:
Hey, guys!

We will soon start using Zilretta in our office but have run into a big of a puzzle. We were told to bill it under CPT J3490, Unclassified Drugs, and to put the information about the drug in box 19. In the past, we have not had any luck with this code and many of the larger payers will reject or deny the charge line. Has anyone tested this for Zilretta?
Click to expand...

Just saw a HCPCS July 1 2018 quarterly update that include a Q code that physician offices can use for this product.
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html

https://www.streetinsider.com/Corpo...+Issued+CMS+Q+code+for+Zilretta/14013038.html

Until July 1, I guess you'll need to keep using the unclassified drug J code.
 
Zilretta codes

Good Morning,

When the Q code mentioned in the above post is effective on 07-01-18, Q9993, is the Q code then used instead of the C code issued, C9469? Is the C code deleted on 07-01-18?
 
Zilretta codes

No, the C-code (C9469) is used by HOPDs and ASCs that bill FFS Medicare using the 1450 claim form (also called UB-04). It does not apply to the physician office setting for FFS Medicare beneficiaries. The Q code will be used for physician office setting for FFS Medicare beneficiaries, starting July 1st.
 
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