Wiki BCG Shortage and Coding

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rcrosse

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I'm sure you have all heard there is a BCG shortage. The latest recommendation for subsequent treatments is to use 1/3 dosage and treat 3 patients from one vial. We have been searching for proper coding since 90586 and J9031 just say each use and it is typically a one dose vial. We have reached out to Medicare, they are researching, have contacted AUA and await their response. Any suggestions of modifier? I have not found anything that looks appropriate for the drug. We don't want to be fraudulent so seeking advice. :eek:
 
So if you are not using the whole dosage per vial, I would recommend reporting the CPT codes with the modifier 52. Supportive documentation may be requested at the discretion of the payer.
 
Does anyone know how to properly bill for 1/3 dosage? I still cannot find a definite answer for how to bill it correctly. Thank you.
 
I tried to bill 51720 and J9031 X.34( for a 1/3 of the vial). It was getting denied. Another urology coder pointed out that J9031 reads per instillation. So, I started billing it normally again.

Machelle Freeman, CPC
 
I have not. I am struggling trying to get Medicare to pay. The AUA instructed in 2018 to bill with J3490 and include the Name of the Drug and the NDC# in box 19. I have done this and Medicare rejected the claim. CSR at Medicare instructed me to rebill without the letters NDC, claim still rejected. I appealed but because the claims rejected and did not deny, the appeal was not accepted. I have called Merck and the told me I need to call the insurance company, I called Medicare and they have no further guidance either. If anyone has gotten Medicare to pay prior to the new code release om 07/01/19, please let me know how.
 
You should now be billing the new J code for BCG...J9030 with 1 mg = 1 unit. Check the price of one unit or one mg.
You will now bill based on the units instilled not on the vial. A vial of BCG contains 50 units or 50 mg of BCG, so to bill for a vial used the fee would be 50 units noted in column 24G and 50 X the fee for one unit.
For a third of the vial given, bill 17 units (noted in box 24G) times the charge for one unit or one milligram.
 
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