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 
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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
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller with 30 years of experience in the healthcare industry.
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