# Payment on compounded drugs for pain pump refills



## deniserue (Oct 20, 2013)

We are billing 62370 for a pain pump refill, with J3490 (unclassified drug) for the compounded drug refill.  We put a description of the medication (drug name, strength, dosage, and invoice price).  We are getting paid on 62370, but are not on the J3490 - any advice?


----------



## wmparkerjax (Oct 25, 2013)

Is this one particular plan, or across the board?


----------



## deniserue (Oct 27, 2013)

Medicare specifically


----------



## wmparkerjax (Oct 28, 2013)

There haven't been any recent changes to processes that I am aware of. Look closely at the requirements for submission. Not properly annotating the claim will cause a denial. For instance: _*An invoice is required for each claim. Electronic submitters should indicate that they have an invoice available upon request by putting "Documentation Available Upon Request" in the electronic equivalent of Item 19 of the CMS 1500 claim form. WPS Medicare will send an ADS (development) letter requesting the invoice, which is needed to make the payment determination. If you do not indicate the availability of the invoice, or if it you do not return it in a timely fashion, the claim may be denied as unprocessable*_.


----------



## deniserue (Oct 28, 2013)

Thank you very much for your response!


----------



## KMCFADYEN (Oct 29, 2013)

We bill for pump refill drugs to medicare using J7799 KD (Prialt is J2278) and we have very few issues with reimbursement.  See medicare billing info below:

Submitting Claims for Compounded Medications, Including Medication Administered via Implanted Infusion Pumps
This article explains the correct method for submitting compounded drugs. 

Compounded medications are created by a pharmacist in accordance with the Federal Food, Drug and Cosmetic Act and may be covered under Medicare when their use meets all other criteria for services incident to a physician’s service. 

Compounded medications do not have a National Drug Code (NDC) number, an average sales price (ASP) or an average wholesale price (AWP). Accordingly, the specific HCPCS J codes for the drugs in the compounded formulation may not be submitted. Instead, providers must use HCPCS code J7799 (unclassified drug) for reimbursement of the compound. 

The use of compounded drugs has been especially prevalent in the filling of implantable infusion pumps. Whether a single agent or a combination of agents is used, the compounded medication must be submitted with HCPCS code J7799 even though the compound is similar to or includes a drug with a specific HCPCS code (e.g., HCPCS code J2275 for preservative free morphine). 

Providers who document and use the true off-the-shelf product without compounding may continue to use the specific HCPCS code. Because non-compounded drugs administered via DME are reimbursed at 95 percent of AWP instead of ASP + 6 percent, the HCPCS KD modifier must be used to indicate this situation. If administered pump dose exceeds MAU for a particular drug, submit documentation to include expected days of therapy on pump (e.g., 18, 30, 40, 60 or 90 day pump). 

When billing for the use of compounded medications, use HPCPS code J7799 on a single claim line, quantity billed = '1', and enter the name and total dose (in mg or mcg) of each drug of the refill in Box 19 of the CMS 1500 or the appropriate comment loop of electronic claims. If box 19 cannot accommodate all the information, attach the information to the paper claim. Evaluation and management codes, pump refilling codes, and pump adjustment codes are also reimbursable if clinically appropriate during the visit. 

Example: Unit of 1 J7799 claim line detail: Entered in Box 19/4010a comment field 'Morphine Sulfate XX mg + Fentanyl YY mcg + Clonidine ZZ mcg' 

Compounded drugs are contractor priced. Palmetto GBA will reimburse compounded drugs for use in implanted infusion pumps by multiplying the price per mcg or mg in the table below by the total number of mcg or mg of each drug used to refill the pump. In addition to the combined allowable calculated by the dosage detailed, a pharmacy compounding fee of $60 per refill will be included in the total allowable for the refill.  


 Medication Price 
  Per mg or mcg 
 Morphine Sulfate  $0.050/mg 
 Hydromorphone  $0.130/mg  
 Bupivicaine  $0.040/mg 
 Tetracaine  $0.040/mg  
 Fentanyl PF  $0.0072/mcg 
 Droperidol  $0.0013/mcg 
 Ketamine  $0.0048/mcg  
 Baclofen  $0.003/mcg  
 Clonidine   $0.001/mcg  
 Sufentanyl  $0.090/mcg  
 Prialt*  $7.900/mcg 


*Prialt is a drug only available from its pharmaceutical manufacturer. If given as single drug in the pump, use HCPCS code J2278. If mixed with other drugs in the pump, consider the mixture a compounded drug and use the HPCPS code J7799. Indicate wastage if portion of a vial is not used by using the JW HCPCS modifier.


----------



## deniserue (Oct 29, 2013)

Kelly,
Thank you greatly for your input!!!  We will get busy resubmitting!!!  Thank you!!!


----------



## tolbert4 (Jan 30, 2016)

*Compounded Drugs*

Does any ones doctors office get there compounded drugs from Bioscript or is there another Pharmacy out there that does this also?


----------



## dswartley (Feb 12, 2016)

Anazao Health Corporation
Hartley Pharmacy
We have used both companies and they are great!


----------



## SALLYCPR (Mar 9, 2016)

*Compounded drugs from Bioscrip*

Hi, we are in texas and get some of our compounded drugs from Bioscrip but some come from Med Shop Total Care in Longview, Texas. Hope this helps.


----------



## shelleywinters2008@yahoo.com (Jun 10, 2016)

*Medicare not paying n J7799*

We just recently started billing with the J7999 and entering the compound drug information in box 19. I received a non payment stating CO-109 claim not covered by this payer.  Any suggestions?


----------

