Sunday, April 17, 2011

CPT code J0696 - INCORRECT Unit submission and general Guidelines

DESCRIPTION OF THE ISSUE

CPT J0696 Rocephin injection was defined incorrectly as 500mg per unit instead of 250mg per unit. 

CONCEPT

When we gave 1 gram = 1000mg, we were billing 2 units, but it should have been 4 units.

SOLUTION

In IMS 500mg was redefined as 250mg per unit through CPT Macros set up. How to create CPT Macros? Goto - Setup and select - Bill – CPT Macros and start setting up Macros.



Sample NDC code list CPT J0696




Billing and Coding Guidelines

Patient receives 1gram of Rocephin IM in the physician/s office.

• NDC for the product used: 00004-1963-02
• Descriptor: Rocephin 500 mg vial in powder form, reconstituted prior to injection.

Report:

• J0696 (ceftriaxone sodium, per 250 mg)
o 4 HCPCS units
• 00004196302 (NDC number)
o UN2 (NDC units as 2, also called 2 each)

J0696 Injection, ceftriaxone sodium, per 250 mg (Rocephin) Maximum 16 units per date of service

J0696 Rocephin Shot Injection IV/IM (Ceftriaxone) Billing Coding

J0696 HCPCS, 90788 CPT, 99201-99215 E/M codes for Rocephin shot (Ceftriaxone) injection (IV/IM) can increase revenue, when used in the right combination.

Yes, you read it right, Rocephin Shot (Ceftriaxone IV Injection) coding can increase medical reimbursement revenue. Yes, it is ethically and legally possible by billing for the procedure, the supply, and the E/M service correctly.

Rocephin (ceftriaxone sodium) is a cephalosporin antibiotic administered as Intramuscular (IM) or Intravenous(IV) injection. It works by fighting bacteria in your body. Rocephin is used to treat many kinds of bacterial infections, including severe or life-threatening forms such as meningitis.

Using CPT Code 90788 for the Rocephin Injection IV will get you $16.80. Use of NDC Code J0696 for Rocephin Short (Ceftriaxone Sodium) will reimburse you $13.35.

For 1 gram of ceftriaxone sodium, bill 4 units J0696 as the increments of 250 mg as 1 unit. It means if a doctor office uses Rocephin (ceftriaxone) 1 gram the code J0696 will be used as 4 units, which is equal to 1000 mg. However, make sure that you are using the correct NDC per vial.


Learn how to document Rocephin Shot (Ceftriaxone Sodium IV Injection) properly:

J0696 Rocephin Shot IV Injection (Ceftriaxone) Coding
For maximum Rocephin shot reimbursement, please follow these steps:
J0696 Rocephin Injection, Ceftriaxone Sodium, Per 250 mg
HCPCS code J0696 should be charged per unit. When Rocephin shot is administered at the medical practice, the medical biller should report CPT 90788 (Intramuscular injection of antibiotic [specify]). Physicians use Rocephin, a type of antibiotic, which you may know by the generic name of ceftriaxone sodium, to treat serious bacterial infections

Even if an insurer doesn’t pay much for 90788, this is the correct code to use. You may mistakenly use 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) as a catchall injection code. But 90782 isn’t for an antibiotic injection. Code 90782 instead describes a therapeutic, prophylactic or diagnostic injection. Translation: Use 90782 for a preventive shot, such as Synagis for respiratory syncytial virus (RSV), or a restorative treatment, like Decadron for croup.The difference between 90782 and 90788 is the injection material. 

Watch out: The only time that you should report 90788 for a Rocephin injection is if your payer instructs you to do so.

90788 CPT Code use for injection

Remember that 90782 includes the administration only -- you still need to bill for the supply. You should report the Rocephin with J0696 (Injection, ceftriaxone sodium, per 250 mg) per 250 mg.

Make sure you charge for the dose that you administer. For each 250 mg of Rocephin, you should bill one unit of J0696. List the unit(s) in the units field of the claim form next to the supply code. If you use a partial unit, such as 600 mg, round up to the next unit.

If appeals fail, consider writing a prescription for Rocephin. If you have a nearby pharmacy, the parent can pick up the antibiotic and return to your office for the injection. But sending the parent out to pick up the Rocephin for a very sick child may not be convenient, timely or appropriate.

99201-99215 E/M Code for office visit

For the evaluation, history and medical decision-making that lead you to administer the injection, you should report an office visit (99201-99215, Office or other outpatient visits for the evaluation and management of a new or established patient …). After examining and assessing the child, the physician decides that an antibiotic injection is the best treatment.

Often, the visit may qualify for a high-level E/M, such as 99214 or 99215. Before Rocephin injections were available, these patients would usually require intravenous antibiotics in the hospital. Now, the pediatrician can give a shot in the office. But the level of risk associated with these cases is still high.




NDC Units: These units are based on the numeric quantity administered to the patient and the unit of measurement. The unit of measurement (UOM) codes follow:

UOM Code  Descriptor

F2 International Unit
GR Gram
ML Milliliter
UN Unit (each)


The actual metric decimal quantity administered and the units of measurement are required for billing. If reporting a fraction (part of a unit), use a decimal point. (I.e. If three 0.5 ml vials are dispensed, report 1.5 ml.).

Examples of how units of measure qualifiers relate to NDC dose/volume:

NDC Dose Volume Unit Qualifier

1,000ML ML
50,000IU F2
1Unit UN
50mg GR
100mg/4ml ML




Facilities                Payment Limit for Drugs when Infused through DME 


J0696 Ceftriaxone sodium injection $13.35 $14.92

J0696 Ceftriaxone sodium injection $14.92

For the UB04 claim form, a CPT or HCPC procedure code must be reported when using pharmacy revenue codes 0250, 0251, 0252, 0254, 0631, 0632, 0633, 0634, 0635, or 0636. When the CPT or HCPC procedure code associated with these revenue codes is on the list below, the NDC code must also be on the claim. Alternatively, a provider may enter all NDC codes for all administered drug items rather than just for the codes below. 



J0696 Injection, ceftriaxone sodium, per 250 mg.



Some NDC Claims to Be Reprocessed for Procedure Codes J0696 and J0886

Information posted March 9, 2012

TMHP has identified an issue that impacts claims that were submitted with procedure codes J0696, or J0886 in combination with specific National Drug Code (NDC) numbers (values). These claims may have been denied in error by Texas Medicaid. Affected claims that were submitted within the last 24 months will be reprocessed and providers may receive additional payment, which will be reflected on Remittance and Status (R&S) Reports.

Claims submitted with the following procedure codes and National Drug Code (NDC) combination will be reprocessed:

Procedure Code         Corresponding NDC

J0696 25021010610  55390031110


J0886 55513028310

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