Billing a Miscellaneous/ Unclassified HCPCS CodeUnclassified HCPCS Code

60889-R5-V1

• Thi i f ti i id d f b k d d ti d• This information is provided for your background education and is not intended to serve as guidance for specific coding, billing, and claims submissions. The decision on which codes best describe the services provided must be made by the individualdescribe the services provided must be made by the individual providers based on specific payor guidance and requirements.

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Overview • Billing and coding for miscellaneous HCPCS* codes• Billing and coding for miscellaneous HCPCS codes• Medicare• MedicaidMedicaid • Private payors

• Claim form submission• Sample CMS-1500• Sample UB-04/CMS-1450

• Tips for submitting a clean claim

*HCPCS – Healthcare Common Procedure Coding System

Unclassified/Miscellaneous Codes • Used when no existing national code adequately

describes the item or service being billed • Allows suppliers to begin billing immediately for aAllows suppliers to begin billing immediately for a

service or item as soon as the Food and Drug Administration (FDA) allows it to be marketedU d d i th i d f ti t f• Used during the period of time a request for a new code is being considered under the HCPCS review process1

1. CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.http://www.cms.gov/MedHCPCSGenInfo/02_HCPCSCODINGPROCESS.asp. Accessed 05/02/2010.

Coding for Physician Administered Drugs

• Drugs are typically reported using product specific HCPCS codes (eg J-code)

HCPCS Code1 Descriptor

J3490 Unclassified drugsHCPCS codes (eg, J code) assigned by the Centers for Medicare & Medicaid Services (CMS)2

g

J3590 Unclassified biologics

fServices (CMS)2

• Until a specific code is assigned, an “unclassified”

J9999 Not otherwise classified, antineoplastic drugs

C9399Unclassified drugs or

code is normally used

1. Centers for Medicare and Medicaid Services, 2012 Alpha Numeric HCPS HCPCS File.

C9399 biologicals(Medicare hospital outpatient setting)

1. Centers for Medicare and Medicaid Services, 2012 Alpha Numeric HCPS HCPCS File. http://www.cms.gov/HCPCSReleaseCodeSets/Downloads/12anweb.zip. Accessed January, 23, 2012.

2. CMS. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures.http://www.cms.gov/MedHCPCSGenInfo/02_HCPCSCODINGPROCESS.asp. Accessed 9/29/2010

Miscellaneous Coding Implications1

• Drug name/generic name• Strength• Dosage administered• Route of administration

• Drug name/generic name• Strength• Dosage administered• Route of administration

Additional information required by

most payors on • Route of administration• National Drug Code (NDC)• Route of administration• National Drug Code (NDC)

p yclaim form may

include:

• Prescribing Information• FDA-approval letter• Any relevant documentation to

support medical necessity (chart or

• Prescribing Information• FDA-approval letter• Any relevant documentation to

support medical necessity (chart or Some payors

may also pp y (laboratory notes, letter of medical necessity, etc)

• Drug purchase invoice

pp y (laboratory notes, letter of medical necessity, etc)

• Drug purchase invoice

yrequest:

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1. WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips. http://www.wpsmedicare.com/j5macpartb/departments/claims/j3490billingtips.shtml . Accessed 11/25/2010.

Medicaid - Billing Unclassified HCPCS CodesPhysician Office

Providers typically need to report the NDC in the national 11-digit format of 5-4-2

Physician Office• Bill on the CMS-1500 or electronic

equivalentE ample HCPCS J3590 or J3490 g

Example:13456-123-12

would be reported as12345012312

• Example HCPCS: J3590 or J3490• NDC is required on Medicaid claims

including the paper CMS-1500, electronic 837P Web interChangeelectronic 837P, Web interChangeclaims and Medicare crossover claims–Reporting instructions vary by payor

1 Centers for Medicare & Medicaid Ser ices (CMS) Transmittal 1401 cms go /transmittals/do nloads/R1401CP pdf1. Centers for Medicare & Medicaid Services (CMS), Transmittal 1401. www.cms.gov/transmittals/downloads/R1401CP.pdf. Accessed 06/03/2010.

2. WPS Medicare (J5 MAC Part B). J3490 (Not Otherwise Classified HCPCS Code): Billing Tips. http://www.wpsmedicare.com/j5macpartb/departments/claims/j3490billingtips.shtml. Accessed.:06/22/2010.

Private Payors - Billing Unclassified HCPCS CodesHCPCS Codes

Physician Office Hospital Outpatient

• Bill on the CMS-1500 or electronic equivalent. Example:– J3590 Unclassified biologics

• Bill on the UB-04/CMS-1450 or electronic equivalent. Example:– J3590 Unclassified biologicsg

– J3490 Unclassified drugs

• Additional information required in

g

– J3490 Unclassified drugs

• Additional information required Box 19 will vary by payor in Field 80 (Remarks) will vary

by payor

Centers for Medicare and Medicaid Services, Transmittal 1924, February 26, 2010. http://www.cms.hhs.gov/transmittals/downloads/R1924CP.pdf. Accessed November 24,2010.

EXAMPLE CLAIM FORMS

Physician Office: Sample CMS-1500

Box 19: List drug name (brand/generic), dosage, route of administration, and NDC

XXX XX

Brand Name (generic name), dose, administered, NDC XXXXXXXXXXX

96372

J3490

Box 21: Enter ICD-9-CM diagnosis code based on the patient’s documented medical record

XXX XX

J3490

Box 24 D: Enter CPT / HCPCS code(s) for procedure and other services provided

Hospital Outpatient: Sample UB-0496372

J3490Field 44: Enter HCPCS / CPT code(s) for procedures and other services provided

Field 69: Enter ICD-9-CM diagnosis code(s) based on documentation in medical record

Field 80: List drug name, XXX

(brand/generic) dosage, and NDC Brand (generic), dose, route of

administration, NDC XXXXXXXXXXX

Reasons for Claim Denial C i l dCommon reasons include:

• Incorrect or transposed patient information (eg, insurance identification number, date of birth)

• Invalid codes – CPT, HCPCS, ICD-9-CM• Missing or incorrect number of units• I t difi l k f difi• Incorrect modifier or lack of a modifier• Service not deemed a medical necessity• Insufficient information to process the claim p

(eg, missing NDC, prior authorization number, invalid NPI) • Site of service mismatch

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Billing correctly the first time may prevent a delay in processing your claim

• Provide appropriate documentation in the patient’s medical record to justify the coding

• If submitting an unclassified/miscellaneous code• If submitting an unclassified/miscellaneous code, include additional information as required by the payor

• Verify your computer software is current and y y pconsistent with built-in edits

• Track clearinghouse claims to ensure successful transmission

• Monitor payor coding and coverage policies

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