# Remicade admin/infusion denials



## ollielooya (Aug 3, 2012)

Hope someone is around this weekend to answer this post.  Doctor provides services in his office with Remicade infusions.  In addition to that he provides a steriodal drip prior to giving the infusions which is also denied.  For this particular patient with a 696.0 diagnosis, Aetna has denied the 96413 and 96415 for missing the required HCPCS code of J1745.   We do not bill the drug to Aetna as patients gets this from an off-site pharmacy.  So, to unlock the  claims edits, do we submit the HCPCS code on the HCFA and charge "0" or .01 charge?  Is this the accepted way to unlock the McKesson edits?


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## Pamela.Bates (Aug 3, 2012)

*Remicade*

[I In Texas for Medicare, We bill Remicade with a chemo administration charge[/I]Medicare uses CPT codes 96413 and 96415 to describe the first and subsequent hours, ... 2012 Coding & Billing for REMICADE® in Physician Offices A quick ...Hope this helps and that I understand your question!


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## ollielooya (Aug 4, 2012)

thanks for responding...it appears you were trying to furnish a reference resource?  Could you please explain further?

Ok, I've done more research.  Perhaps an additional modifier is needed when a patient brings in their own meds or obtains from outside pharmacy.  So, I'm thinking that we should go ahead and bill the drug with the corresponding units and submit that "0" or 0.1 charge with a KX modifier to stipulate that the requirements specified in the medical policy have been met?  Wonder if even Aetna recognizes this modifier?  What do you all think?  Might it work?

Would I be able to find out this information from a call to customer service at Aetna and move to a higher level, request the aid of a supervisor, or.....just skip this altogether and go straight to the provider rep? This will continue to be an ongoing issue with us and I'd like to see our doctor get paid for the services he provides!!!


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## mitchellde (Aug 4, 2012)

Suzanne,
We have always billed our patient supplied drugs with the J code and the ..  .01 charge, and then adjust the  .01 off.  We use no modifier, and as long as the medical necessity for the drug is met we are reimbursed for the administration.


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## ollielooya (Aug 4, 2012)

Thanks Debra, as I know you post some answers on the weekend and was hoping you might see my plea!  Based upon what I've found and these confirmations will resubmit the claims with the .01 charge and adjust the write-off.  If for some reason, this fails, will follow thru with provider support.

I found a policy from Trailblazer (courtesy of another poster) where it specifically states they want the KX modifier, so was kinda curioius as to whether any of the commercials do likewise.. Thanks for responding.


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