Primary Care Coding Alert

Question: We have been getting denials from one of our payers whenever one of our providers administers dexamethasone to reduce inflammation in patients that suffer from such conditions as myalgia, allergic rhinitis, or acute sinusitis. Is there anything we can do to get these claims accepted?

Mississippi Subscriber

Answer: There are a number of issues that could be affecting such claims. Here are three things you should check before resubmitting the claims to your payer.

1. First, make sure everything is accurate in your claim. To bill for the dexamethasone, use an appropriate HCPCS code for the form of dexamethasone administered, such as J1100 (Injection, dexamethasone sodium phosphate, 1 mg), along with the correct number of units used and an appropriate CPT^® code to describe the administration, such as 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). Additionally, make sure you have used the correct diagnosis code, such as J01.- (Acute sinusitis) or J30.9 (Allergic rhinitis, unspecified), to justify the drug treatment.

2. Next, make sure you have used the correct national drug code (NDC) for the dexamethasone. You can find the NDC on the package containing the drug, or by going to the U. S. Food and Drug Administration (FDA) National Drug Code Directory at www.accessdata.fda.gov/scripts/cder/ndc/index.cfm. You will also need to add the N4 prefix (which indicates the use of the NDC) to the drug’s NDC.

3. Lastly, check your payer’s policy to make sure there are no restrictions on using the dexamethasone, which is a steroid, for the treatment of the conditions you mention above. Aetna’s current policy on reimbursing for allergy and hypersensitivity treatments, for example, regards the use of “intramuscular [IM] steroids for the treatment of acute sinusitis and allergic rhinitis,” as “experimental and investigational as they have not been proven to be effective” (See www.aetna.com/cpb/medical/data/1_99/0038.html). This could well be the cause of the denial.

The remittance advice accompanying the denied claim should provide an explanation for the denial. If it does not, then contact the payer to determine the reason and use that as a starting point for identifying whether the problem rests with the claim or payer policy.