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Thread: Propofol

  1. #1
    Join Date
    Apr 2007

    Default Propofol

    AAPC: Back to School
    I am trying to find the J code for propofol. Right now we are using J3490 Unclassified drugs for Propofol and including the description and NDC # on each claim. Over and over the J code is denied and we have to call and explain that all the info they need is on the claim. The claim is usually reprocessed and paid out. Any suggestions on getting this paid the first time? Thanks!

  2. #2
    Join Date
    Apr 2007
    Nashville AAPC Chapter


    This information might be helpful, see the notation in red.

    Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs
    Effective January 1, 2011 through March 31, 2011

    Note 1: Payment allowance limits subject to the ASP methodology are based on 3Q10 ASP data.

    Note 2: Providers should contact their local Medicare contractor processing the claim for the most appropriate unlisted/unclassified HCPCS code to use in reporting these drugs to Medicare.

    Note 3: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug.

    Similarly, the inclusion of a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category.

    These determinations shall be made by the local Medicare contractor processing the claim.

    Claims submitted to Medicare Part B for Not Otherwise Classified (NOC) Drugs (e.g., J3490 - J9999) MUST contain the NAME of the drug administered and dosage on the 1500 form in box 19 or for EMC claims, it must be submitted in the comment field. Per Medicare Claims Processing Manual, Chapter 26 - Completing and Processing, Form CMS-1500 Data Set, the NDC number for an unlisted drug is not enough information to correctly price your claim.
    The NDC number for an unlisted drug is not enough information to correctly price your claim.

    Claims submitted without the name of the drug and dosage will deny with the message “Missing/incomplete/invalid name, strength, or dosage of the drug furnished.”

  3. #3

    Default New code for Propofol

    Effective 7-1-14 Propofol 10 mg is S0144. Listed in the HCPCS quarterly updates on CMS website.

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