For claims submitted to the Part B MAC
Claims for collagenase clostridium histolyticum, for the Part B MAC, should be submitted using HCPCS code J3590 (unclassified biologics) with the name " collagenase clostridium histolyticum " or " Xiaflex ™" and the dosage listed in Item 19 of the CMS-1500 claim form or the electronic equivalent. The drug and administration code should be submitted on the same claim. Injection of collagenase clostridium histolyticum and stretching of the cord are payable in the following places of service: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgical center (ASC) (24), nursing facility for patients not in a Part A stay (32) and independent clinic (49). The collagenase clostridium histolyticum is payable in the following places of service: office (11), nursing facility for patients not in a Part A stay (32) and independent clinic (49).
For claims submitted to the Part A MAC
Hospital outpatient perspective payment system (OPPS) claims submitted to the FI or Part A MAC should use HCPCS code C9399 to report collagenase clostridium histolyticum “or " Xiaflex ™. Report the National Drug Code (NDC), the quantity of the drug that was administered (milligrams) and the date the drug was administered in FL 80, remarks for the CMS-1450 or its electronic equivalent.
Bill Type Codes:
11x Hospital-inpatient (including Part A)
13x Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
85x Special facility or ASC surgery-rural primary care hospital (eff 10/94)
20550 INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (EG, PLANTAR ’’FASCIA’’) - Fee schedule amount - $ 59.62
26989 UNLISTED PROCEDURE, HANDS OR FINGERS
29130 APPLICATION OF FINGER SPLINT; STATIC Fee schedule amount - $41.82
C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS
J3590 UNCLASSIFIED BIOLOGICS
Billing and Coding Guideline for CPT CODE 20550
Morton's neuromas injections do not involve the structures described by CPT codes 20550 and 20551 or direct injection into other peripheral nerves but rather the injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using CPT codes 20550, 20551, 64450, or 64640. Most specifically, the provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas.
Injections for plantar fasciitis are billed with CPT code 20550 and ICD-9-CM 728.71. Injections for calcaneal spurs are billed as other tendon origin/insertions with CPT code 20551.
For example, CPT code 20550 (“Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)”) describes a therapeutic musculoskeletal injection. It is a misuse of this code to report it for the injection of local anesthesia in order to perform another procedure such as a hallux valgus correction (CPT code 28292). Therefore, CPT code 20550 is bundled into CPT code 28292.
LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)
The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for CPT 20526, 20550, 20551 or 20612.
Morton’s Neuroma: 64450, 64640, and 20550 Not Reimbursable with Diagnosis 355.6
This rule will deny 64450, 64640 or 20550 when billed with diagnosis 355.6. This is supported by AMA/CPT which developed specific codes for these services for this
ICD-9 Codes that are Covered
Sources of Information and Basis for Decision
CPT CODE J3590 Unclassified biologics
NDC is required on Medicaid claims including the paper CMS-1500, electronic 837P, Web interChange claims and Medicare crossover claims –Reporting instructions vary by payor
Providers typically need to report the NDC in the national 11-digit format of 5-4-2
Example NDC code 51927-1000-00 Morphine Sulfate POWD and 24856-0001-00 Jetrea 0.5MG/ 0.2ML SOLN
On CMS 1500 Additional information required in Box 19 will vary by payor
On ub 04 Additional information required in Field 80 (Remarks) will vary by payor
• J3490 or J3590 are approved and valid codes for Bevacizumab when treating neovascular age-related macular degeneration (AMD) by an Ophthalmologist. The administration CPT code for the administration of J3490 or J3590 is 67038.
Compounded Medications Billing - Providers must use HCPCS code J3490 (unclassified drug), HCPCS code J3590 (unclassified biologic), or HCPCS code J9999 (NOC antineoplastic drug)
• What is a KD Modifier?
• Drug or biological infused through DME implantable pump
• A single charge should be submitted, whether a single agent or a combination of agents, using HCPCS code J3490, J3590, or J9999, as appropriate, with the KD modifier
Billing tips for CPT cod C9399
Beginning January 1, 2004, hospital outpatient departments may bill for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which pass-through status has not been approved and a C-code and APC payment have not been assigned, as follows:
o Beginning on and after the date of FDA approval, hospitals may bill for the drug or biological using a new “unclassified” drug/biological code, C9399, Unclassified drug or biological.
FIs shall advise hospitals to report such drugs and biologicals in revenue code 0636 with HCPCS code C9399, and showing the following data elements on the ANSI ASC X- 12 837 I: the NDC code (Loop 2400 LIN 03), quantity administered (UNITS) expressed in the unit of measure applicable to the drug or biological (Loop 2400 SV205) and line item date of service (LIDOS) (Loop 2400, DTP Date of Service), the CMS-1450, or its electronic equivalent (UB-92 flat file, v.6.0, Record Type
FIs shall make payment to hospital outpatient departments for HCPCS code C9399 at 80 percent of 95 percent of AWP for the particular NDC code, after deductible has been met.
Reporting Codes for Mixed Drugs and Biologicals
Report correct HCPCS code separately if two or more drugs or biologicals mixed together
• Two or more mixed does not constitute a “new” drug
• Not appropriate to bill HCPCS code C9399 - Unclassified Drug or Biological
– C9399 is for FDA-approved drugs and biologicals for which a HCPCS code had not been assigned
HCPCS C9399 – Unclassified Drug or Biologica
C9399 is for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which a specific HCPCS code has not been assigned
• For use on Part A claims submitted to MAC only
Special Billing Instructions for C9399
FISS DDE MAP171E – Include CPT Segment NDC Number, NDC Quantity, and NDC Qualifier to be listed for the HCPC C9399
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