Ask the Contractor Teleconference
Topic: Drug
Administration Code Changes & Chemotherapy Demonstration Project
Questions & Answers
Question: When you are billing for an IM code and an injection, do
you need do you need a modifier on the EM code?
Answer: Procedure code 99211 is not covered when billed with an
IM administration code. Modifier -25 is needed when any other Evaluation
& Management code is billed with the IM drug administration code.(revised following the ACT)
Question: Why are you doing audits on Remicade?
The information requested in the questionnaire is very clinical. Who is
reviewing these claims? I am concerned that a rheumatologist should be
examining these claims. Who is the medical director for
Answer: We do random sampling on certain codes every month.
These claims are reviewed by registered nurses. They may also be referred to
physician consultants. The carrier medical director may also get involved. The
medical director for
Question: When is CMS going to come through with the change for IV
push vs. IV infusion?
Answer: We are waiting for that change to come through. We will
post the information on our website when we hear from CMS.
NOTE: Change Request 3818 was published
on April 15, with an implementation date of May 16. For more information
on the changes, please go to http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3818.pdf.
Question: Does the chemotherapy demonstration project include
“risk” Medicare members (patients) or just traditional Medicare members?
Answer: This project is limited to traditional Medicare
patients.
Question: How do we bill electronically for unlisted J-codes?
Answer: Electronically, you should bill them like any other
unlisted service. Use your comments field to indicate the description of the
drug and dosage and bill with J9999. Your software should associate your
comments with the applicable line. Your software vendor can give you more
clarification for reporting unlisted codes.
Question: We provide the initial chemotherapy infusion in the
office and then send the patient home with a portable pump. There is a code for
chemotherapy infusion for more than 8 hours. Do we use this code or how should
we bill for the filling and maintenance of the pump that is sent home with the
patient?
Answer: You do not use the code for more than 8 hours. Portable
pumps are bundled when used in the office. You can use 96520 and modifier 59
for filling of the portable pump that the patient will take home on the same
day.
Question: When we administer Cisplatin,
we add potassium and mannitol to the bag. Can we
charge for all 3 drugs or just the one infusion going in?
Answer: Yes, you can charge for the cost of the additional drugs
but only bill for one infusion.
Question: Protocols call for Oxaliplatin
and Leucovorin to be administered at the same time.
You can put both at the y-site of the needle. How do we bill this?
Answer: Currently, there is no code for concurrent
administration of chemotherapy drugs. You can get further coding help from
contacting your specialty associations.
Question: Can we use telephone review for chemotherapy
demonstration claims and drug administration claims that have been denied
incorrectly?
Answer: These codes must be billed on the same claim. Denied
demonstration codes that have been paid because they were not billed on the
same claim or they did not point to the cancer diagnosis can be re-billed
electronically as long as there is a covered administration paid on the same
day. NHIC looks at the beneficiary history to help make these determinations.
Based on the reason for denial, other G codes can be appealed through the
regular appeals process.
Question: When billing for the port flush (G0363), can you also
bill J1642—heparin flush?
Answer: No, you cannot bill for the heparin flush.
Question: How should we bill for multiple hours (units) of IV
infusion?
Answer: You can use an initial code for the first hour (for
example G3047) and you can use an additional code (for example G3048) to report
the subsequent hours. The majority of the new G codes can take multiple units.
Question: When you have 2 lines going in for IV infusions, how do
we bill for the 2 units of G0359?
Answer: The 1st claim line bill G0359 and 1 unit of
service; the 2nd line bill G0359 with modifier 76 and 1 unit of
services. You can’t bill for multiple units of this code.
Question: When billing for Remicade,
should we use G0359?
Answer: Yes, you should use the G0359 chemotherapy
administration.
Question: Can G0351 (therapeutic or diagnostic injection) be
billed on the same day as a level one office code—99211?
Answer: No, you can’t bill a diagnostic injection or infusion on
the same day as 99211. You do not need a modifier 25 if it is billed with any
other service.
NOTE: Following the call, we verified that a
modifier -25 is needed on E&M services billed with this code, with the
exception of the 99211, which cannot be billed with it.
Question: On the Demonstration Project, some secondary carriers do
not recognize the project. Are the Medicare beneficiaries then responsible for
the co-payments?
Answer: True Medigap plans have been
instructed by CMS and they should pay the co-payments due on these claims. We
cannot be certain that other secondary insurers will pay. The beneficiaries
Remittance Notice will advise them on their financial responsibility on the
claim. You should notify your patients that they will be responsible for the
coinsurance. You must document the medical information in the patient’s records
regarding their responses to the patient assessment levels.
Question: Have you published a list of drugs that fall under
G0355? What about Zolaire?
Answer: No, we have not published a list of drugs for any of
these new G codes. Zolaire is usually considered a
therapeutic drug and it can be billed with G0351.
Question: When billing electronic claims, some services are
separated on the remittance notice, why are these lines split and
separated? How many lines will come over electronically?
Answer: NHIC can receive twenty or more lines of service
electronically. Many vendors or clearing houses limit their claim
transmissions to the standard 6 lines. Check with your vendor to
determine what their limits are, and submit your lines of service to ensure they
are not split.