Sunday, April 17, 2011

CPT code J0696 - INCORRECT DEFINITION IN SOFTWARE

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



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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