October 20, 2014

Colorectal Cancer Screening ICD 9 and CPT Codes

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Colorectal Cancer is one of the leading causes of cancer deaths in the United States. Approximately 56,290 people died from colorectal cancer, and 145,290 people were newly diagnosed with the disease in 2005. Colorectal cancer is usually found in people ages 50 and older. Therefore, screening for colorectal cancer for people ages 50 and older is strongly recommended.

Fortunately, Colorectal cancers are some of the most preventable cancers because screening tests can detect growths before they become cancerous. Most colorectal cancers develop from polyps (growths on the lining of the colon). Polyps are usually noncancerous when they first appear. But they can turn into cancerous polyps (adenoma). Removal of these polyps can reduce risk of colon cancer by more than 80 percent.

Colon cancer most commonly occurs in the lower part of the colon. Cancer in the rectum is called rectal cancer. Together, they are referred to as colorectal cancer.

Colorectal Cancer Screening ICD 9 and CPT Codes

Colon cancer happens when cells that are not normal grow in your colon. These cells grow together and form tumors. Colonoscopy is the only colorectal screening test that examines the entire colon and can remove any polyps found during the test. There are other colorectal cancer screening tools, but colonoscopy is the gold standard.

Colorectal Cancer Screening ICD 9 for Colonoscopy

Colonoscopy is a widely used endoscopic technique used to screen individuals for colorectal cancer. It is very sensitive in detecting colorectal cancers. Colonoscopy is an endoscopic procedure in which a thin tube with a camera at the tip is introduced through the anus till the start of the colon.

Colorectal Cancer Screening ICD-9-CM diagnosis code for an average risk patient presenting for colonoscopy is:

V76.51 Special Screening for Malignant Neoplasm, Colon
Code V76.51 should be the first listed diagnosis code if the reason for the visit is specifically for the screening exam. For high risk patients, the appropriate family or personal history V code identifying the risk should also be assigned. As with screening for malignant neoplasm of the breast, if a condition is discovered during the screening then the code for the condition may also be assigned as an additional diagnosis.

If the colonoscopy is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code. However, if positive findings are discovered during the diagnostic colonoscopy assign the code for these findings instead.

Colorectal cancer screening tests and procedures can be used alone or in various combinations and include fecal blood test, barium enema, flexible sigmoidoscopy and colonoscopy. Colonoscopy screening procedures are discussed here.

Colonoscopy CPT Codes for Colon Cancer Screening

After the patient's bowel has been prepped, the physician inserts the colonoscope-a long, thin, flexible lighted tube-through the anus and advances the scope through the colon past the splenic flexure. The lumen of the colon and rectum is visualized. Most polyps and some cancers can be removed during this procedure. The colonoscope is then withdrawn.

HCPCS Level ll codes G0105 and G0121 should be reported for Medicare outpatients requiring screening colonoscopy for colorectal cancer:
  • G0121 Colorectal cancer screening, colonoscopy on individual not meeting criteria for high risk
  • G0105 Colorectal cancer screening, colonoscopy on individual at high risk
According to Medicare, a patient is considered to be at high risk if he or she has any of the following risk factors:
  1. Close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp
  2. Family history of familial adenomatous polyposis
  3. Family history of hereditary nonpolyposis colorectal cancer
  4. Personal history of adenomatous polyps
  5. Personal history of colorectal cancer
  6. Inflammatory bowel disease, including Crohn's disease and ulcerative colitis
Screening colonoscopy for non-Medicare patients is coded with 45378, Colonoscopy, flexible, proximal to splenic flexure, diagnostic.

If an abnormality is found during a screening colonoscopy and results in a therapeutic procedure, then the appropriate diagnostic colonoscopy CPT code (45379-45392) is used instead of codes G0105, G0121 or 45378. Therapeutic procedures include biopsy, polypectomy, etc.

Review the CCS Prep column titled, "Understanding How to Code Colonoscopies" for instructions on coding therapeutic procedures.
Example: A patient is seen in the outpatient clinic for screening colonoscopy due to family history of colon cancer. The colonoscopy revealed a colonic polyp that was removed by snare technique. Assign CPT code 45385.

For Medicare OPPS coding, when a screening colonoscopy is attempted but due to extenuating circumstances cannot be completed, code G0105 or G0121 should be reported with either modifier -73 or -74 as appropriate.

October 13, 2014

Breast Cancer Screening ICD 9 and CPT Codes

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Breast Cancer is the most common type of cancer in women in the United States. However, there are screening procedures available to diagnose breast cancers in the early stage.

We are listing the Breast Cancer Screening ICD and CPT Codes invloved in the diagnoses and procedures coding for screening malignant neoplasm of the breast.

Breast Cancer Screening ICD 9 and CPT Codes

Screening is the testing for diseases in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. If testing is performed because the patient has a sign or symptom, the sign or symptom code is used to explain the reason for the test, not the screening code.

A screening code may be the first listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an encounter for other health problems. If a condition is discovered during the screening, the code for the condition may be assigned as an additional diagnosis.

Breast Cancer Screening ICD 9 and CPT Codes

The following ICD 9 V Code categories are reported to indicate that a screening exam is planned. A procedure code is also required to confirm that the screening was performed. ICD 9 V73-V82 Special screening examinations are used for the purpose.

When the reason for performing a test is because the patient has had contact with, or exposure to, a communicable disease, the appropriate code from category V01, Contact with or exposure to communicable diseases, should be assigned, not a screening code.

ICD 9 Codes for Breast Cancer Screening Mammograms

Every woman is at risk for developing breast cancer, and the risk increases with age. According to the Center of Disease Control and Prevention (CDC), approximately 94 percent of breast cancers are diagnosed in women older than age 40. Mammography is the best available way to detect breast cancer early, when it is most curable. Timely screening can reduce breast cancer mortality in women 40 and older by 17 percent to 30 percent.

The National Cancer Institute (NCI) guidelines for screening mammography recommend that asymptomatic women 40 years or older be screened every 1 to 2 years and women aged 50 or older be screened every 1 to 2 years. NCI further recommends that younger women who are at higher risk for developing breast cancer consult with their physician regarding screening mammography and the frequency of such screenings.

Diagnostic mammograms differ from screening mammograms. Screening mammograms are for patients without documented problems. Diagnostic mammograms are performed when there is a problem such as a breast mass, pain, discharge, etc. Code any positive findings found on the diagnostic mammogram as the first listed diagnoses. If there are no reported findings, assign the reason for the test. The ICD 9 diagnoses codes for encounters for screening mammogram are:
  • V76.11 and V76.12 Special screening for malignant neoplasm, other screening mammography.
  • V76.11, Special screening for malignant neoplasm, screening mammogram for high-risk patients.
Example: A healthy 40-year-old woman presents to the radiology department for a screening mammogram. The patient has no symptoms or known risks for breast cancer. Assign code V76.12.
The following ICD 9 codes may be assigned with code V76.11 to identify why the patient is considered to be at high-risk:
  • V10.3, Personal history of malignant neoplasm, breast
  • V16.3, Family history of malignant neoplasm, breast
  • V15.89, Other specified personal history presenting hazards to health, other
Example: A woman with no symptoms is referred to the hospital for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. Assign code V76.11 followed by code V16.3.
If a condition is found during the screening, then the code for the condition may be used as an additional diagnosis. The rationale for this is that even though a condition is found during the mammography, the visit is still considered a screening.

For Medicare services, diagnosis codes V76.11 and V76.12 must be the first listed diagnosis on all encounters for screening mammography services. However, effective Oct. 1, 2006, this requirement will change to allow the reporting of any applicable diagnosis code as a primary diagnosis on claims containing other services in addition to a screening mammography. Continue reporting diagnosis codes V76.11 and V76.12 as the first listed diagnosis codes on claims that contain only screening mammography services.

Breast Cancer Mammography CPT Codes

A mammogram is a low-dose X-ray of the breast that can find lumps that are too small to be felt during a breast examination. The breast is compressed firmly between two planes and pictures are taken. This spreads the tissue and allows for a lower X-ray dose. A screening mammogram is used to detect breast changes in women who have no signs of breast cancer. When the patient has signs or symptoms of a suspected disease then a diagnostic mammogram is performed and coded instead.

A screening mammogram is inherently bilateral and is reported with Breast Cancer Screening CPT Codes 76092 and G0202 given below:
  • 76092, Screening mammography, bilateral (two view film study of each breast)
  • G0202, Screening mammography, producing direct digital image, bilateral, all views
Code 76083, Computer aided detection (CAD); screening mammography, may be assigned as an additional procedure code when it is performed in addition to the primary procedure. The additional CAD code indicates that a laser beam was used to scan the mammography film and then the image was converted to digital data for computer analysis.

As mentioned earlier, if a condition is discovered during the screening, then the code for the condition may be used as an additional diagnosis. In this instance, if the radiologist performing the mammogram orders additional films based on the condition discovered during the screening mammogram, both may be coded.

When a screening mammogram is converted to a diagnostic mammogram on the same day append modifier GG, Performance and payment of a screening mammography and diagnostic mammography on same patient same day, to the diagnostic mammography code. Modifier GG indicates that the test changed from a screening test to a diagnostic test. If not performed on both breasts, it is also important to append the appropriate anatomic modifier, RT or LT, to indicate which side the diagnostic mammogram was performed on.

October 6, 2014

Radiation Oncology CPT Codes and Billing Coding Guidelines

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Learn all about Radiation Oncology CPT Codes and Billing Coding Guidelines. Radiation Oncology is a specialty that involves treatment of various forms of Cancer through radiation. This forms of therapy use carefully selected targeted and regulated doses for the process of killing cancer cells.

The cancer cells normally die as a result of destruction of chromosomes and DNA, preventing them from further growing, thus preventing a tumor from growing.

Radiation Oncology CPT Codes and Billing Coding Guidelines

For proper reimbursement from insurance companies, Medical Billing staff working for a Radiologist, Oncologist or Radiology Practice need to document proper disease and diagnosis coding through the use of ICD and CPT codes.

Radiation Oncology CPT Codes and Billing Coding Guidelines

Radiology CPT codes comprise of 70,000 series of codes that are normally organized depending on the type of radiology and the purpose of the service. Radiation oncology CPT code are normally classified as shown below:
  • Diagnostic Radiology CPT Codes 70000 - 76499
  • Diagnostic Ultrasound CPT Codes 76500 - 76999
  • Radiologic Guidance CPT Codes 77001 - 77032
  • Breast, Mammography CPT Codes 77051 - 77059
  • Bone/Joint Studies CPT Codes 77071 - 77084
  • Radiation Oncology CPT Codes 77261 - 77999
  • Nuclear Medicine CPT/HCPCS Codes 78000 – 79999
Two CPT codes are primarily used for reporting Intensity Modulated Radiation Therapy (IMRT). CPT Code 77301 for Radiotherapy dose planning, and CPT Code 77418 for Radiotherapy treatment delivery.

Radiation CPT code 77301 is commonly utilized as an intensity modulated radiotherapy plan that includes dose volume histograms for target and critical structure partial tolerance specifications.

Radiation CPT code 77418 is one the other hand normally used as a delivery single or multiple fields/arcs via narrow spatially and temporary modulated beams. CPT code 77418 is a technical-component only code which can be used by physicians when services are performed in a non-facility setting such as the office.

Billing Radiation Oncology Services

Radiological service can be billed for the physician's work as well as the use of equipment or supplies. The technical component (TC) includes facility charges, equipment, supplies, pre/post injection services, staff and so on. The professional component (PC) involves studying and making inferences about the radiological test and submitting a written report with the findings.

Radiation Oncology CPT Code Modifiers

Modifiers are used to signify the technical and professional components in a radiological service. They are 2-digit numbers that are used to explain a procedure in more detail. They can indicate repeat or multiple procedures, such as radiography performed bilaterally. When billing for the technical component only, the modifier 52 has to be used; when billing only for the professional component, the modifier 26 is to be used. In the latter case, a written report by the physician providing the services is required to avoid claim denial.

Some of the main challenges that radiologists face include understatement of procedures carried that many at times result in insufficient reimbursement. On the other hand overstatement might result in risk of abuse repayments and fines.

Radiologists can resolve all these issues by going in for the services of professional medical coding companies. That's why Radiology Practices need professional Medical Billers skilled to document correct ICD and CPT coders to do the job.

You can also checkout Echocardiogram CPT Codes, CPT codes for MRI of Brain, Breast, Lumbar Spine and Shoulder, Cardiology CPT Changes and other Medical Billing and Coding Updates 2014 to learn further.

Effective reimbursement of Radiation Oncology services, in-depth knowledge of the medical billing coding systems, application of coding principles, and thorough understanding of documentation is required. That's why most of the professional companies utilize Best Medical Billing Softwares to guarantee efficiency and accuracy in billing and coding, for checking local coverage determination and so on to ensure that all claims are reimbursed.

September 29, 2014

Arteriovenous (AV) Fistula/Shunt/Graft:36147 vs 36148,75791

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Learn the difference between CPT Code 36147 vs 36148, 75791 for correct coding of Arteriovenous (AV) Fistula/Shunt/Graft.

An arteriovenous fistula is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm.

While if we take a look at Arteriovenous (AV) Shunt definition according to CPT guidelines:
For diagnostic studies, the arteriovenous (AV) dialysis shunt (AV shunt) is defined as beginning with the arterial anastomosis [opening between two normally separate structures] and extending to the right atrium.
This definition includes all upper and lower extremity AV Shunts, Arteriovenous Fistulae (AVF) and Arteriovenous Grafts(AVG).

Arteriovenous (AV) Fistula/Shunt/Graft:36147 vs 36148,75791

An AVF for dialysis is surgically created by cutting an opening in an artery and an opening in a nearby vein and then joining the openings together so that blood can communicate between the artery and the vein. An AVG also involves creating openings in an artery and a vein, but uses an artificial vessel to link the two openings

Arteriovenous (AV) Fistula, Shunt, Graft: 36147 vs 36148 vs 75791

Medical Coders typically use CPT 36147 for patients with end-stage renal disease (ESRD), having trouble with his AV shunt for dialysis and requires an evaluation.

CPT can pack a lot into one little code. Let's take a closer look at Arteriovenous (AV) Fistula/ Shunt/ Graft coding with using CPT codes 36147, 36148 and/or 75791:

36147 Access AV Dial Grft for Eval

CPT Code 36147 Description
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava).
When CPT Code 36147 is Used
CPT Code 36147 is reported when the physician performs a fistulagram to evaluate a dialysis arteriovenous fistula or graft. This code includes all components of the fistulagram, including the work of the initial puncture into the graft or fistula and all of the necessary imaging from the arterial anastomosis through the entire venous outflow – including the central veins and superior or inferior vena cava. This code also includes all of the catheter manipulation to perform the diagnostic examination, including advancement of the catheter to the cava if necessary to fully visualize the central veins.

36148 Access AV Dial Grft for Proc

CPT Code 36148 Description
Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (list separately in addition to code for primary procedure).

When CPT Code 36148 is Used
CPT Code 36148 was established to describe the placement of a second (additional) access that may be necessary to perform a therapeutic procedure (e.g., percutaneous transluminal angioplasty, thrombolysis). Please note that code 36148 is an add-on code that is reported only in conjunction with code 36147.

75791 AV Dialysis Shunt Imaging

CPT Code 75791 Description
Angiography, arteriovenous shunt (eg, dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation.

When CPT Code 75791 is Billed
CPT Code 75791 is reported to describe the imaging of the arteriovenous dialysis fistula or graft performed through an existing access (e.g., patient presents from the dialysis suite with needles placed into the graft or fistula, or from a remote access such as the femoral artery that is not a direct puncture to the graft, or images from an operative angiogram that are submitted for interpretation only). The imaging includes the entire length of the graft or fistula and all of the outflow veins through the central veins, including the vena cava.

When procedure codes 36147 and 75791 are used to report the services described in this LCD (appropriate evaluation of the patency of an established hemodialysis fistula and the percutaneous interventions needed to enhance or re-establish patency of that hemodialysis fistula), the following diagnosis codes will be considered by Medicare to support medical necessity:

CodeICD code description
440.31ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES
440.32ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES
442.0ANEURYSM OF ARTERY OF UPPER EXTREMITY
442.3ANEURYSM OF ARTERY OF LOWER EXTREMITY
444.21ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY
444.22ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY
447.0ARTERIOVENOUS FISTULA ACQUIRED
447.1STRICTURE OF ARTERY
451.82PHLEBITIS AND THROMBOPHLEBOTIS OF SUPERFICIAL VEINS OF UPPER EXTREMITIES
453.40ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY
453.41ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY
453.42ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY
453.50CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY
453.51CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY
453.52CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY
453.6VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITY
453.71CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY
453.72CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY
453.73CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED
453.74CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS
453.75CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS
453.76CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS
453.77CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS
453.79CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
453.81ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY
453.82ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY
453.83ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED
453.84ACUTE VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS
453.85ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS
453.86ACUTE VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS
453.87ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER THORACIC VEINS
453.89ACUTE VENOUS EMBOLISM AND THROMBOSIS OF OTHER SPECIFIED VEINS
459.2COMPRESSION OF VEIN
996.1MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.62INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT
996.73OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT
996.74OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT

A medical coder should report 36148 (additional access for therapeutic intervention [List separately in addition to code for primary procedure]) in addition to 36147 if the initial evaluation (36147) prompts a therapeutic intervention requiring a second shunt catheterization.

CPT Code 36148 is not used to identify a second diagnostic injection procedure from a second access point. Use 36148 when an interventional procedure is provided from that second access point.

If percutaneous access had already been established prior to the service, 36147 would not be appropriate. You should instead report 75791 (Angiography, arteriovenous shunt [e.g. dialysis patient fistula/graft], complete evaluation of dialysis access, including fluoroscopy, image documentation and report [includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava], radiological supervision and interpretation).

September 22, 2014

XE,XS,XP,XU with CPT Modifier 59 for Medicare Reimbursement

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As we has already posted that Modifier 59 has been split between XE, XS, XP, XU sub codes for Medicare reimbursement. These CPT Modifier 59 Changes takes effect from Januaray 2015, under Distinct Procedural Service.

XE, XS, XP, XU with CPT Modifier 59 for Medicare Reimbursement

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

XE,XS,XP,XU with CPT Modifier 59 for Medicare Reimbursement

CR8863 discusses changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
  • Different encounters.
  • Different anatomic sites.
  • Distinct services.
The -59 modifier is:
  1. Infrequently (and usually correctly) used to identify a separate encounter.
  2. Less commonly (and less correctly) used to define a separate anatomic site.
  3. More commonly (and frequently incorrectly) used to define a distinct service.
The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59
modifier:
  • XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.
  • XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure.
  • XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner.
  • XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of
the -59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.

However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.

September 15, 2014

HCPCS Code J3490 Medicare Reimbursement Billing Guidelines

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Learn HCPCS Code J3490 billing guidelines for Medicare Reimbursement. It is used for non-coded drugs unlisted NDC number.

HCPCS Code J3490 Medicare Reimbursement Billing Guidelines

J3490 Medicare Reimbursement and Coverage

The 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 Guidelines

HCPCS 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:
    1. Name and Strength of Drug Administered
    2. Amount Given
    3. NDC Number

J3490 NDC number for Drugs Unlisted

If 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)