J3490 Medicare Reimbursement and CoverageThe Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.
CMS Medicare offers two codes for unlisted drugs: J9999 Unclassified Chemotherapy Drugs and J3490 Unclassified drugs for others. The more commonly used unlisted drug code is J3490. With an unlisted drug code, it is needed to document the importance of trying this new drug and record it in the chart notes. If the physician tried listed drugs and they didn't work, you need to make sure the claim includes that information.
The main drugs that now require unlisted codes are Neulasta and Faslodex, both of which are non-chemotherapy drugs and therefore require J3490. The two main chemotherapy drugs that require J9999 are Velcade and Oxaliplatin.
HCPCS Code J3490 Billing GuidelinesHCPCS code J3490 is a non-specific code that should be used only when another J-code does not describe the drug being administered (CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug. For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code).
If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490. Billing requirements for HCPCS codes J3490 (Unclassified Drugs) and J3590 (Unclassified Biologics) are as follows:
- Providers may submit claims for J3490 and J3590 only when a specific code for the drug is not available or does not exist.
- The claim form must include the following information in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim form or on a separate attachment:
- Name and Strength of Drug Administered
- Amount Given
- NDC Number
J3490 NDC number for Drugs UnlistedIf the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.
For billing of compounded drugs administered via implanted pump, submit a single combined line item for all drugs with HCPCS Code J3490 and bill the combined charges for all drugs.
For Electronic Claims
Indicate the name(s) and dose(s) of each drug being submitted in the documentation record.
For Paper Claims
- Indicate Compunded drugs, invoice attached in Item 19 of the CMS-1500 Claim Form
- Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)
- Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g INV $250.00)