cpt code and description
J0702 - Injection, betamethasone acetate 3mg and betamethasone sodium phosphate 3mg
J1030 - Injection, methylprednisolone acetate, 40 mg
J1100 - Injection, dexamethasone sodium phosphate, 1mg
j3301 INJECTION TRIAMCINOLONE ACETONIDE NOS 10 MG
Example#1: J1100-Dexamethasone, 1 mg Your bottle says 4 mg/ml
If you use 0.25 cc (1 mg) = 1 Unit
If you use 0.5 cc (2 mg) = 2 Units
If you use 0.75 cc (3 mg) = 3 Units
If you use 1.0 cc (4 mg) = 4 Units
Example#2 J1030 methylprednisolone acetate, 40 mg (Depo-Medrol)
Your bottle says 40 mg/ml
If you use 0.25 cc 10 mg = 1 Unit
If you use 0.5 cc 20 mg = 1 Unit
(J1020=methylprednisolone acetate, 20 mg )
If you use 0.75 cc 30 mg = 1 Unit
If you use 1.0 cc 40 mg = 1 Unit
Example#3 J3301 triamcinolone acetonide, (Kenalog-10, Kenalog-40) per 10 mg
Your bottle says Kenalog 40 =40 mg/ml
If you use 0.25 cc 10 mg/40 mg = 1 Unit
If you use 0.5 cc 20 mg/40 mg = 2 Units
If you use 0.75 cc 30 mg/40 mg = 3 Units
If you use 1.0 cc 40 mg/40 mg = 4 Units
The CPT code J3301, Kenalog injection is a good example of an NOC code that must be used. Read the user manual for instructions for submitting NDC numbers. You need to change your insurance layout and enter the NDC number using the format specified in the user manual.
To report the Kenalog, use the HCPCS code J3301. This J code is for triamcinolone acetonide per 10mg. The instructions for this code state to use for Kenalog- 10, Kenalog-40, Triam-A. This code may be billed in multiple units. Thus, if 20mg were used, report J3301 with 2 in the units box (box 24G on the CMS -1500 form).
Example#4 J0702 betamethasone acetate and betamethasone phosphate, per 3 mg
(Celestone Soluspan 6 mg/ml)
If you use 0.25 cc 1.5 mg/6 mg = 1 Unit
If you use 0.5 cc 3 mg/6 mg = 1 Unit
If you use 0.75 cc 4.5 mg/6 mg = 1 Unit
If you use 1.0 cc 6 mg/6 mg = 2 Units
CPT CODE J2001 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG
the following services will not be eligible for separate reimbursement when identified as services that are included in the global surgical package when they are reported by the surgeon or by providers of the same group with the same specialty Please refer to the Bundled Services and Supplies Policy for additional information:
Fluid and drug administration services such as therapeutic, prophylactic, and/or local anesthetic injections (e.g., J2001 and 96372)
20526 8520527 20550 20551 20552 20553 20555 20555 20600 20605 20610 20612 20615 27096 64479 64480 64483 64484 64490 64491 64492 64493
Anthem Central Region bundles J2001 as redundant/mutually exclusive to 20526-20527, 20550-20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495. Based on the National Correct Coding Initiative Edits, code J2001 is listed as a component code to codes 20526-20527, 20550-20553, 20600- 20615, 27096, 64479, 64483, 64490-64495. Therefore, if J2001 is submitted with 20526-20527, 20550- 20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495—only 20526-20527, 20550-20555, 20600-20615, 27096, 64479, 64480-64484, 64490-64495 reimburses .
• In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationship examples:
Units calculation example
The following are key points to remember when billing Medicare for rituximab (J9310):
• J9310 is defined in the HCPCS manual as: Injection, rituximab, 100 mg
• One (1) unit represents 100 mg of rituximab ordered/administered per patient
• Rituximab should be billed based on units not the total number of milligrams
o For example, if the quantity administered is 200 mg and the description of the drug code is 100 mg, the units billed should be two (2).
The following are key points to remember when billing Medicare for bevacizumab (J9035 or C9257):
• C9257 is defined in the HCPCS manual as: Injection, bevacizumab, 0.25 mg
• J9035 is defined in the HCPCS manual as: Injection, bevacizumab, 10 mg
• One (1) unit represents 10 mg of (J9035) or 0.25 mg (C9257) of bevacizumab ordered/administered per patient
• Bevacizumab should be billed based on unit not the total number of milligrams
o For example, if the quantity administered is 300mg and the description of the drug code is 10 mg, the units billed should be thirty (30).
Supplemental Information Related to Reporting Drugs
The following serves to clarify billing guidelines and provide examples of proper billing with a singledose vial and discarded drug billing:
• Providers and hospitals are reminded to ensure that amounts of drugs administered to patients are accurately reported in terms of the dosage specified in the long descriptors for the applicable HCPCS codes. This is because the short descriptors are limited to 28 characters so they do not always capture the complete description of the drug.
• When submitting Medicare claims, units should be reported in multiples of the dosage included in
the long HCPCS descriptor. If the dosage given is not a multiple of the number provided in the HCPCS code description, the provider shall round up to the nearest whole number in order to
express the number as a multiple.
• If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Medicare may cover the amount of the drug discarded along with the amount administered. The following elements must be followed in order for the discarded amount to be covered.
1. The vial must be a single-use vial. Multi-use vials are not subject to payment for any discarded amounts of the drug.
2. The units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient code is 10 mg, the units billed should be thirty (30).
Physician Drug List by Name
The following table provides a listing of valid physician drug codes sorted alphabetically by name. To view this list sorted numerically, refer to Section H.3, Physician Drug List by Procedure Code.
The inclusion or exclusion of a procedure code on this list does not imply Medicaid coverage, reimbursement, or lack thereof. To inquire regarding any restrictions/limits on these procedure codes, please consult the Provider Assistance Center at 1-800-688-7989. The pricing file must be verified to determine coverage and reimbursement amounts.
The following drugs can be injected subcutaneously, intramuscularly, or intravenously.
J0702 INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE SODIUM PHOSPHATE, PER 3 MG NO
J CODE Procedure list
Abraxane Paclitaxel J9264
Factrel Vial w/ Diluent Gonadorel Hydrochloride J1620
Actemra Tocilizumab J3262
Faslodex Fulvestrant J9395
Actimmune Interferon gamma 1B J9216
Flebogamma Immune Globulin J1572
Aldurazyme Laronidase J1931
Flolan Epoprostenol J1325
Alferon N Interferon Alfa-N3 J9215
Gamma globulin, intramuscular, 1cc Immune Globulin J1460
Alimta Pemetrexed Disodium J9305
Gamma globulin, intramuscular, over 10cc Immune Globulin J1560
Aralast Alpha 1 proteinase J0256
Gammagard S/D, Gammargard Liq Immune Globulin J1569
Aranesp Darbopoietin J0881, J0882
Gammaplex Immune globulin C9270
Avastin Bevacizumab J9035, C9257
Gammar-P.I.V. Immune Globulin J1566
Avonex Interferon beta 1-a J1826, Q3025, Q3026
Gamunex Immune Globulin J1561 Belimumab Benlysta Q2044
Genotropin Cartridge Somatotropin J2941
Betaseron Vial Interferon beta 1-b J1830
Genotropin Miniquick Somatotropin J2941
Botox Botulinum toxin Type A J0585
Herceptin Trastuzumab J9355
Campath Alemtuzumab J9010
Hizentra Immune Globulin J1559
Carimune NF Immune Globulin J1566
Humatrope Cartridge Somatotropin J2941
Ceredase Alglucerase J0205
Humatrope Vial Somatotropin J2941
Cerezyme Imiglucerase J1786
Humira Pen Kit Adalimumab J0135
Cimzia Kit Certolizumab pegol J0718
Humira Syringe Adalimumab J0135
Copaxone Glatiramer Acetate J1595
Hyalgan Hyaluronate J7321
Dysport Abobotulinum Toxin A J0586
Immune Globulin Immune Globulin J1566 J1559, J1599, 90281, 90283
Eloxatin Oxaliplatin J9263
Increlex Mecasermin J2170
Enbrel Kit Etanercept J1438
Infergen Interferon Alfacon-1 J9212
Epogen or Procrit Erythropoietin J0885, J0886, Q4081
Infergen Vial Interferon Alfacon-1 J9212
Erbitux Cetuximab J9055
Intron A Inj Pen Interferon alfa-2b J9214
Euflexxa Hyaluronate J7323
Kineret Syr Anakinra J3490
Extavia Interferon beta-1b J1830
Leukine Sargramostim; GMCSF J2820
Fabrazyme Agalsidase Beta J0180
Lucentis Ranibizumab J2778
Lumizyme Alglucosidase Alfa C9257, C9277
Prokine Sargramostim J2820
Macugen PFS Pegaptanib J2503
Prolastin Alpha 1 proteinase J0256
Myobloc Botulinum toxin Type A J0587
Proleukin Aldesleukin, IL-2 J9015
Myozyme Alglucosidase Alfa J0220
Rebif Syringe Interferon beta 1-a Q3025, Q3026, J1826, J1830
Naglazyme Galsulfase J1458 Remicade Infliximab J1745
Neulasta 6mg/0.6ml PFS Pegfilgrastim J2505
Remodulin Treprostinil J3285
Neupogen Filgrastim; G-CSF J1440, J1441 Rituxan Rituximab J9310
Nordiflex Somatropin J2941
Rocephin for lyme disease Ceftriaxone Sodium J0696
Norditropin Somatropin J2941
Saizen Injection Somatotropin J2941
Norditropin CRTG Somatropin J2941
SCig Immune globulin 90284
Novantrone Mitoxantrone J9293
SCIg Immune Globulin Subcutaneous [Human] 90284
NuSpan Somatropin J2941
Serostim Vial Somatropin J2941
Nutropin AQ Somatropin J2941
Somatrem Somatrem J2940
Nutropin AQ Pen Cartridge Somatropin J2941
Somatropin Somatropin J2941
Nutropin AQ Vial Somatropin J2941
Stelara Ustekinumab J3357
Nutropin Depot Somatropin J2941
Supartz Hyaluronic acid J7321
Nutropin Vial Somatropin J2941
Synagis Palivizumab 90378
Octagam Immune Globulin J1568
Synvisc Hyaluronate J7325
Omnitrope Somatropin J2941
Synvisc One Hyaluronate J7325
Orencia Abatacept J0129
Tev-Tropin Somatropin J2941
Orthovisc Hyaluronate J7324
Tyvaso TREPROSTINIL J7686
Panglobulin Immune Globulin J1563
Vectibix Panitumumab J9303
Pegasys Vial Peginteferon Alfa 2a S0145
Velcade Bortezomib J9041
Peg-Intron RD Pen Kit Peginteferon Alfa 2a S0148
Veletri Epoprostenol J1325
Polygam S/D Immune Globulin J1563
Ventavis Lloprost Q4074
Prialt Ziconotide J2278
Vidaza Azacitidine J9025
Privigen Immune Globulin (Human) IV Soln J1459
Vpriv Velaglucerase alfa J3385
Xeomin IncobotulinumtoxinA Q2040
Xiaflex Collagenase, clostridium histolyticum J0775
Xolair Omalizumab J2357
Zemaira Alpha 1 proteinase J0256
Zobtrive Somatropin J2941
Why is UnitedHealthcare enforcing the NDC on professional drug claims?
A. We are enforcing this requirement as part of our effort to reduce overall costs to the health care system. NDCs are the industry standard identifier for drugs and provide full transparency to the medication administered. They accurately identify the manufacturer, drug name, dosage, strength, package size and quantity
What drug codes require the NDC to be submitted on professional claims effective Jan. 1, 2017?
A. The following drug codes are required:
** J codes, including miscellaneous and unlisted drug codes
** Drug-related CPT codes, including miscellaneous and unlisted drug codes, immunizations, Synagis, and Immune globulin
** Drug-related Q codes, including miscellaneous and unlisted drug codes, Contrast
** Drug-related S codes including Testopel
** Drug-related A codes, including miscellaneous and unlisted drug codes, and adiopharmaceuticals
The NDC will not be enforced for G codes and P codes
Where is the NDC located?
A. The NDC is found on the prescription drug label of the drug container (e.g. vial, bottle or tube). The NDC is a universal number that identifies a drug or related drug item. The NDC number consists of 11 digits with hyphens separating the number into three segments in a 5-4-2 format. The first five digits identify the manufacturer of the drug and are assigned by the FDA. The remaining digits are assigned by the manufacturer and identify the specific product and package size.
Sometimes the NDC on the label does not include 11 digits. If this occurs, it will be necessary to add a leading zero to the appropriate section to create a 5-4-2 configuration (i.e.66733-0948-23 in the following sample). A valid NDC without spaces or hyphens should be placed on the medical claim. The NDC submitted must be the actual valid NDC number on the container from which the medication was administered.
NDC Unit of Measure (UOM)
UOM Description General Guidelines
F2 International unit International units will mainly be used when billing for Factor VIII-Antihemophilic Factors
GR Gram Grams are usually used when an ointment, cream, inhaler, or bulk powder in a jar are dispensed. This unit of measure will primarily be used in the retail pharmacy setting and not for physician-administered drug billing.
ML Milliliter If a drug is supplied in a vial in liquid form, bill in millimeters.
UN Unit If a drug is supplied in a vial in powder form, and must be reconstituted before administration, bill each vial (unit/each) used.
EXAMPLE NDC BILLING SCENARIO
To assist you with making the transition to billing with NDCs, we will be providing some example scenarios based on inquiries we are receiving from providers. This month’s scenario features a high-volume J code.
What was administered?
In our sample scenario, a patient receives 3 mg betamethasone acetate and betamethasone phosphate in the physician’s office. Code J0704 - injection, betamethasone sodium phosphate, per 4mg was deleted effective Dec. 31, 2010. Code J0702 - CELESTONE® SOLUSPAN® Injectable Suspension is a sterile aqueous suspension containing 3 mg per milliliter betamethasone, as betamethasone sodium phosphate, and 3 mg per milliliter betamethasone acetate. Since this is the drug that was administered, then code J0702 is appropriate.
What’s on the package label?
Here are some examples of NDC information that you may see when you are preparing to bill with HCPCS code J0702 betamethasone acetate and betamethasone phosphate, per 3 mg:
• 00517-0720-01 6MG/ML SUSP Unit of Measure 5ML
• 54868-0206-00 6MG/ML SUSP Unit of Measure 5ML
• 58016-9191-01 6MG/ML SUSP Unit of Measure 5ML
What to include on the claim:
The initial dosage of CELESTONE SOLUSPAN Injectable Suspension may vary from 0.25 to 9.0 mg per day depending on the specific disease entity being treated. For the patient in our sample scenario, you will use the NDC on the package label (e.g., NDC is 00517-0720-01, which is CELESTONE SOLUSPAN 6mg/ml in suspension form). There are 5 milliliters (ML) per vial. You will bill J0702 (betamethasone acetate and betamethasone phosphate, per 3 mg) with the NDC unit of measure as ML, and NDC units as 0.5 milliliters (ML0.5) for one 3mg dose.
Insufficient Documentation - 80% of Total Errors
Reasons for errors:
* Billed is CPT J1030 and 20610 - Methylprednisolone 40 MG injection. Missing order and documentation of Methylprednisolone 40 MG injection was administered. Received a partially illegible office visit note that list B-12 as the injection, and office visit notes.
* Injected supply billed with HCPCS “J” codes
* Do NOT bill for the local anesthetic (lidocaine, etc.)
* J1020-30 methylprednisolone acetate (Depo-Medrol)
* J1094 dexamethasone acetate (Decadron LA)
* J1100 dexamethasone sodium phosphate
* J3301-3 triamcinolone (Kenalog)
* Code based upon total mg applied on date of service; even if applied over multiple sites
* Use applicable modifiers to reflect separate sites
* LT, RT, -59 Modifier
What information do I need to have ready before converting HCPCS/CPT units to NDC units ?
Before you can fill out the claim to bill for a drug, you will need to know the following information:
* Amount of drug to be billed
* HCPCS/CPT code
* HCPCS/CPT code description
* Number of HCPCS/CPT units
* NDC (11-digit billing format)
* NDC description
* NDC unit of measure
Consider the following example for Ciprofloxacin IV 1200 MG (1 day supply):
Amount of drug to be billed:
HCPCS/CPT code description:
Ciprofloxacin for intravenous infusion, 200 MG
Number of HCPCS/CPT units
NDC (11-digit billing format):
Ciprofloxacin IV SOLN 200 MG/20 ML
NDC unit of measure