Find-A-Code Articles, Published 2015, June 15

Billing for Unlisted Drug Codes J3490 J9999 and C9399

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jun 15th, 2015 - Reviewed/Updated Aug 8th

When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes you can find pricing for most unlisted drugs on the CMS website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html external link .

For local coverage determinations (LCDs) pertaining to an unlisted drug, refer to the Medicare Policies and Guidelines/LCD's in Find-A-Code. Please note, however, that most unlisted drugs are not covered by an LCD.

Carriers do not need to report radiopharmaceuticals, Fiscal Intermediaries must report radiopharmaceuticals using C9399

If two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each product usedin the care of the patient.

Units should be reported in multiples of the units included in the HCPCS code descriptor.

For example;

If the description for the drug code is 6 mg, and 6 mg of the drug was administered to the patient, the units billed should be 1.

As another example, if the description for the drug code is 50 mg, but 200 mg of the drug was administered to the patient, the units billed should be 4. Providers and hospitals should not bill the units based on the way the drug is packaged, stored, or stocked.

That is, if the HCPCS code descriptor for the drug code specifies 1 mg and a 10 mg vial of the drug

was administered to the patient, bill 10 units,even though only 1 vial was administered.

Medicare contractors will manually price the drug or biological at 95 percent of the Average

Wholesale Price (AWP).

Be sure to include the following

The National Drug Code (NDC)
The quantity of the drug that was administered (expressed in the unit of measure applicable to the drug or biological); and
The date the drug was furnished to the beneficiary

References/Resources

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6492.pdf

About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.

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Find-A-Code Articles, Published 2015, June 15

Billing for Unlisted Drug Codes J3490 J9999 and C9399

References/Resources

About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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