Outpatient Facility Coding Alert

Published on Mon Jan 07, 2013 PDF

Question: Our ASC keeps getting denials for drug supply charges during injections and infusions. Any ideas of what might be the problem?

Vermont Subscriber

Answer: It’s difficult to pinpoint the reason behind the denials without knowing which denial codes the payers are sending. Consider these common mistakes and whether they might be the root of your problem.

When you submit a claim for drug payments, in many cases, it is now necessary to also include the full drug name, the total dosage or units administered, method of administration, and the National Drug Code (NDC) number on the claim form. If you are missing any of that information, you may see rejections for that reason.

You may be putting the wrong number of units in box 24G on the CMS-1500 form, or using the wrong administration code to go with the drug you are reporting.

Example: The physician administers 4 mg IV Zometa over a period of more than 15 minutes. According to the code descriptor for Zometa (J3487, Injection, zoledronic acid [Zometa], 1 mg), you will report the 4 milligram dosage with the number 4 in column 24G of the CMS-1500 form indicating the 4 milligrams were given since the code is based on a 1 milligram dose. Because the Zometa was administered by an infusion greater than 15 minutes, you would also use administration code 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to one hour).

Warning: If your provider has the patient pick up the drug somewhere else, such as a pharmacy, and bring it to your office, you cannot report the drug supply as your office has not incurred the cost of the drug. Just bill for the administration of the drug, and note in Box 19 of the 1500 form or its electronic equivalent the drug information noted above. Also note that the patient has supplied this drug for your administration.