DESCRIPTION OF THE ISSUE
Medicaid requests NDC# for CPTs J3420 and J3301. Initially we have incorrectly filed claims without NDC# and they were denied for requests of NDC# update.
CONCEPT
All J codes should be filed with NDC# updates for Medicaid.
SOLUTION
We requested NDC# update from the Client by compiling the list of denied claims. For which we received NDC# as 005-170-03125 only for CPT J3420. Claims that were denied for the given procedure were refiled with appropriate NDC# and got paid. NDC# request for CPT J3301 is still in pending on the table of Dr’s office.
Triamcinolone Acetonide Kenalog 10mg INJ J3301
Vitamin B12 o Cyanocobalamin 1000mcg IM/SC J3420
BILLING Guide for CPT J3301
NOTE: When giving injectable medications in the office, make sure your doctor is letting the billing department know how many Milligrams not how many CCs they are giving.
EXAMPLES
J3301 Kenalog is billed out per 10 mg If you gave 40 mg, it would be billed as J3301 x 4 units
J1885 Toradol is billed out per 15 mg If you have 30 mg, it would be billed as J1885 x 2 units
J0696 Rocephin is billed out per 250 m If you have 1 g, it would be billed as J0696 x 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).
Guidelines related to Maximum Units
Procedure codes have been assigned a maximum number of units that may be billed per day for a member, regardless of the provider. When a provider bills a number of units that exceeds the daily assigned allowable unit(s) for that procedure, the excess units will be denied. Some procedure codes have been assigned a maximum number of units that may be billed within a 12 month period for a member. Those services would not be done more than once within a year, or twice a year for bilateral procedures. If a provider bills a number of units that exceed the annual assigned allowable unit(s) for that procedure for a member, the excess units will be denied.
Anatomical modifiers E1-E4 (Eyes), FA-F9 (Fingers), and TA-T9 (Toes) have a maximum allowable of one unit per anatomical site for a given date of service. Any service billed with an anatomical modifier for more than one unit of service will be adjusted accordingly. Certain obstetrical diagnostic services may have assigned maximum units per day limits based upon presence or absence of diagnosis codes indicative of multiple gestation. Units billed in excess of the maximum per day limits will be denied.
Team surgery and co-surgery maximums are handled separately and are edited based on the same provider, not at the member level. When the same provider bills a number of units of team surgery or co-surgery that exceed the daily assigned allowable unit(s) for that procedure for the same member, the excess units will be
denied.
Each claim line is adjudicated separately against the maximal units of the code on that line. Blood glucose test or reagent strips (A4253) is limited to 20 units (boxes) per quarter for patients with insulin dependent diabetes, and 6 units (boxes) per quarter for patients with non-insulin dependent diabetes. Per unit reimbursement for allergy immunotherapy is based on the number of dosages prepared and intended for administration. Allergy immunotherapy is limited to 180 units for the first year of therapy during escalation, and 120 units for yearly maintenance therapy thereafter.
Multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (CPT 77338) is reported once per IMRT plan and is limited to 3 units per 60 day treatment course.
In the unusual clinical circumstance when the number of units billed on the claim exceeds the assigned maximum number for that procedure, clinical documentation of the number of units actually performed could be submitted for reconsideration.
Injections
The following procedure codes are a benefit only when they are performed by an APRN, physician, or dentist in the office setting, or by a hospital in the outpatient setting:
Procedure Codes
J0290 J0295 J0330 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1020 J1030 J1040 J1094 J1100 J1170 J1200 J1364 J1580 J1700 J1710 J1720 J1850 J1885 J1890 J1940 J2010 J2400 J2460 J2510 J2540 J2560 J2650 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3430 J3480 J3490 J3520 J0280
Procedure codes J1631, J1790, and S0021 are a benefit for hospitals when they are performed in the outpatient setting and are no longer a benefit when they are performed by a physician or dentist in the inpatient or outpatient hospital setting.
Provider Type and Place of Service Changes
The following procedure codes are a benefit for podiatrists when they are provided in the office setting:
Procedure Codes
J0120 J0290 J0295 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1200 J1364 J1459 J1580 J1885 J1890 J2010 J2400 J2460 J2510 J2540 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3490
Documentation requirement
Another example of insufficient or missing documentation was documented on another MAC’s website. This case involved the billing of HCPCS J1030- Methylprednisolone 40mg 8 units of service and J3301- Triamcinolone 10mg 8 units of service (in addition to CPT 99213, 20610 and 20551-RT/LT). The name/dose of medication administered was missing in the medical record documentation. The records submitted included an unsigned office visit note that is missing the name/dose of medication to be injected and which joints were injected with Methylprednisolone and which joints were injected with Triamcinolone acetonide. Documentation submitted for this case did not meet requirements per Medicare guidelines.
It is important to accurately document the patient’s medical record with all services performed/ordered. Documentation for injections must include the following:
• Name of drug injected
• Location of injection
• Dosage of injection given
• Route of administration
• Signed and dated physician order to include the drug name, dosage, route of administration and duration of treatment
A CERT reviewer also found insufficient documentation to support a continued arthrocentesis procedure (CPT 20610 X3) and Methylprednisolone 80 mg injection (J1040 X3). The medical record was missing a plan of treatment to support continued need for injections as billed. This case also lacked medical necessity for ongoing extended treatment for a chronic condition that has not shown improvement in a reasonable time and treatment has become supportive rather than corrective in nature and is then considered maintenance treatment. Per claim history, arthrocentesis procedure (X3) and Methylprednisolone 80 mg injection (X3) billed every three months since 2009 and additional submitted documentation indicates ongoing injections prior to 2009.
Pain management physicians need to understand in treating chronic pain that maintenance services are not considered medically reasonable or necessary under Medicare. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy. Upon medical review, maintenance treatment will be denied.
Triamcinolone Acetonide Kenalog 10mg INJ J3301
Vitamin B12 o Cyanocobalamin 1000mcg IM/SC J3420
BILLING Guide for CPT J3301
NOTE: When giving injectable medications in the office, make sure your doctor is letting the billing department know how many Milligrams not how many CCs they are giving.
EXAMPLES
J3301 Kenalog is billed out per 10 mg If you gave 40 mg, it would be billed as J3301 x 4 units
J1885 Toradol is billed out per 15 mg If you have 30 mg, it would be billed as J1885 x 2 units
J0696 Rocephin is billed out per 250 m If you have 1 g, it would be billed as J0696 x 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).
Guidelines related to Maximum Units
Procedure codes have been assigned a maximum number of units that may be billed per day for a member, regardless of the provider. When a provider bills a number of units that exceeds the daily assigned allowable unit(s) for that procedure, the excess units will be denied. Some procedure codes have been assigned a maximum number of units that may be billed within a 12 month period for a member. Those services would not be done more than once within a year, or twice a year for bilateral procedures. If a provider bills a number of units that exceed the annual assigned allowable unit(s) for that procedure for a member, the excess units will be denied.
Anatomical modifiers E1-E4 (Eyes), FA-F9 (Fingers), and TA-T9 (Toes) have a maximum allowable of one unit per anatomical site for a given date of service. Any service billed with an anatomical modifier for more than one unit of service will be adjusted accordingly. Certain obstetrical diagnostic services may have assigned maximum units per day limits based upon presence or absence of diagnosis codes indicative of multiple gestation. Units billed in excess of the maximum per day limits will be denied.
Team surgery and co-surgery maximums are handled separately and are edited based on the same provider, not at the member level. When the same provider bills a number of units of team surgery or co-surgery that exceed the daily assigned allowable unit(s) for that procedure for the same member, the excess units will be
denied.
Each claim line is adjudicated separately against the maximal units of the code on that line. Blood glucose test or reagent strips (A4253) is limited to 20 units (boxes) per quarter for patients with insulin dependent diabetes, and 6 units (boxes) per quarter for patients with non-insulin dependent diabetes. Per unit reimbursement for allergy immunotherapy is based on the number of dosages prepared and intended for administration. Allergy immunotherapy is limited to 180 units for the first year of therapy during escalation, and 120 units for yearly maintenance therapy thereafter.
Multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (CPT 77338) is reported once per IMRT plan and is limited to 3 units per 60 day treatment course.
In the unusual clinical circumstance when the number of units billed on the claim exceeds the assigned maximum number for that procedure, clinical documentation of the number of units actually performed could be submitted for reconsideration.
Injections
The following procedure codes are a benefit only when they are performed by an APRN, physician, or dentist in the office setting, or by a hospital in the outpatient setting:
Procedure Codes
J0290 J0295 J0330 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1020 J1030 J1040 J1094 J1100 J1170 J1200 J1364 J1580 J1700 J1710 J1720 J1850 J1885 J1890 J1940 J2010 J2400 J2460 J2510 J2540 J2560 J2650 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3430 J3480 J3490 J3520 J0280
Procedure codes J1631, J1790, and S0021 are a benefit for hospitals when they are performed in the outpatient setting and are no longer a benefit when they are performed by a physician or dentist in the inpatient or outpatient hospital setting.
Provider Type and Place of Service Changes
The following procedure codes are a benefit for podiatrists when they are provided in the office setting:
Procedure Codes
J0120 J0290 J0295 J0530 J0540 J0550 J0560 J0570 J0580 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0704 J0710 J0715 J0720 J0744 J1200 J1364 J1459 J1580 J1885 J1890 J2010 J2400 J2460 J2510 J2540 J2700 J2770 J2920 J2930 J3000 J3260 J3301 J3302 J3303 J3370 J3490
Documentation requirement
Another example of insufficient or missing documentation was documented on another MAC’s website. This case involved the billing of HCPCS J1030- Methylprednisolone 40mg 8 units of service and J3301- Triamcinolone 10mg 8 units of service (in addition to CPT 99213, 20610 and 20551-RT/LT). The name/dose of medication administered was missing in the medical record documentation. The records submitted included an unsigned office visit note that is missing the name/dose of medication to be injected and which joints were injected with Methylprednisolone and which joints were injected with Triamcinolone acetonide. Documentation submitted for this case did not meet requirements per Medicare guidelines.
It is important to accurately document the patient’s medical record with all services performed/ordered. Documentation for injections must include the following:
• Name of drug injected
• Location of injection
• Dosage of injection given
• Route of administration
• Signed and dated physician order to include the drug name, dosage, route of administration and duration of treatment
A CERT reviewer also found insufficient documentation to support a continued arthrocentesis procedure (CPT 20610 X3) and Methylprednisolone 80 mg injection (J1040 X3). The medical record was missing a plan of treatment to support continued need for injections as billed. This case also lacked medical necessity for ongoing extended treatment for a chronic condition that has not shown improvement in a reasonable time and treatment has become supportive rather than corrective in nature and is then considered maintenance treatment. Per claim history, arthrocentesis procedure (X3) and Methylprednisolone 80 mg injection (X3) billed every three months since 2009 and additional submitted documentation indicates ongoing injections prior to 2009.
Pain management physicians need to understand in treating chronic pain that maintenance services are not considered medically reasonable or necessary under Medicare. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the treatment is then considered maintenance therapy. Upon medical review, maintenance treatment will be denied.
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