Oncology & Hematology Coding Alert

Question: We performed the following services:

Dexamethsone: 10:03-10:20

Benadryl^®: 10:25-10:40

ULTOMIRIS^®: 11:13 – 11:57 3300mg

We split the claim to Medicare as the drug charge is in excess of $99,999. However, we are getting an N522 denial as the drug codes on all three claims are bumping against one another. Should we use a 59 modifier, and should we apply it on a second claim line or even a third?

North Carolina Subscriber

Answer: As you point out, according to the Centers for Medicare & Medicaid Services (CMS) Standard Companion Guide Health Care Claim: Professional (837P), you cannot submit a claim electronically when the submitted characters in any dollar field are greater than $99,999.99. Additionally, CMS will deny claims if they receive more than one claim for the same service/procedure on the same date of service if there is no explanation as to why they are receiving two claims with the same CPT^® or HCPCS Level II code.

So, if your amounts do exceed the limit, and the claim does need to be split, your first claim should include the dexamethasone, Benadryl^®, and ULTOMIRIS^® HCPCS Level II codes for the drug administered as well as the appropriate administration codes. Bill the ULTOMIRIS^® with units that will ensure the claim is less than $99,999.99. You will also need to include a note in the narrative field that this is claim 1 of 2.

Your second claim should include the ULTOMIRIS^® code with the remaining units, again keeping the claim with an amount less than the maximum dollar amount. You will need to append modifier 59 (Distinct procedural service) to your second claim, adding a note to this claim’s narrative field indicating that it is claim 2 of 2.

This means your claims should look something like this:

Claim 1

• 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour)
• +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure))
• +96375 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure))
• J1100 (Injection, dexamethasone sodium phosphate, 1 mg) with appropriate units based on what was administered to the patient
• J1200 (Injection, diphenhydramine HCl, up to 50 mg) with appropriate units based on what was administered to the patient
• J1303 (Injection, ravulizumab-cwvz, 10 mg) with 165 units
• Note in the narrative field that this is claim 1 of 2

Claim 2

• J1303 with 165 units
• Append modifier 59 and a note in the narrative field that this is claim 2of 2

For further reference: Go to the CMS Standard Companion Guide Health Care Claim: Professional (837P) https://www.ngscedi.com/documents/20124/298626/837P_CG_CEDI.pdf/53f5c638-c6c9-7da4-8969-497f16f136c2?t=1673042055965.