Wiki Billing injections with 5FU and Kenalog-40 mixture

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AmandaF

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My physician injects a mixture (9:1) of 5 FU and Kenalog-40 total is usually 0.3-1cc into scars or chalazions. Would the medications be billed separately with the J3301 Kenalog and J9190 for 5 FU? And would you do the interlesional or sub-q injection code?
Thanks for your help.
 
I don't see any response to this back in 2011 but I have this same question regarding treating symptomatic keloids, can you charge for both kenalog and 5FU? and do I use cpt 11900 or 96405?
 
I'll attempt to answer this.

Think of it this way... What is the difference between having 1 syringe of each and injecting each medication separately, vs. combining them into the same syringe. Nothing. What is important is calculating the units correctly for J3301 and J9910 based on the concentrations, total volume administered. This where your high-school math and algebra comes into play. (Remember in high school when you swore you'd never use or need algebra?)

So you can bill J3301 and J9910 separately in correct units (after your math homework has been completed).

It's possible that after math, the J3301 will be a fraction of a unit, (since you are diluting 9:1) and you'd just round up to 1 unit. And calculate the same for the F-5U

As backup for my claim, according to Noridian, this doesn't meet the definition of a compounded drug

https://med.noridianmedicare.com/web/jeb/topics/drugs-biologicals-injections

"Mixing two or more pre-packaged products in the same syringe when prepared according to label instructions, does not meet the definition of a compounded drug."

Therefor, i'd conclude that you have to bill the J-codes individually.


Which procedure code to use?

For injecting scars, use 11900/11901 for Kenalog. CPT 96405 is typically used for injecting scars with 5-FU. But you can't code both codes. Pick one. You'd have a good defense with 96405 since 90% of the medicine being injected is 5-FU.

Even though 11900/96405 is based on lesion count, if the scar is large enough and you have to inject several sites on the same scar, you can count those as separate injections (i.e.lesions). Document CLEARLY the size of the scar being injected (dimensions) to cover your behind in an audit and I'd include wording that stated "due to the size of the fibrous tissue, it required injections at multiple sites/locations. Even photo or drawing showing the lesion and marks approximating the injection sites would help.
 
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Math

9:1 5 FU: Kenalog

If you mix 9 CC (ml) of 5-FU and 1 CC of Kenalog 40, it's a total of 10 CCs,

Kenalog is there for 1/10th or 10% of the total combined medication injected

So lets say you injected 3 CCs of the final mixture into the scar

10% of 3 CCs = 0.3 CCs Kenalog injected. Now each CC of Kenalog = 40mg, therefore 0.3 x 40mg per CC = 12 mg. This gets rounded up to 2 units of J3301 since each unit of J3301 = 10 mg

90% of 3 CCs = 2.7 CCs of F-5U injected. Now each CC of F-FU = 500mg, therefore 2.7 x 500mg per CC = 1350 mg. This gets rounded up to 3 units of J9190 since each unit of J9190 = 400 mg
 
thank you so much for the calculations and explanation of the combo injection! wonderful :)

Since you are using 5FU which normally is coded with admin 96405 because chemo drug, just wondering why not use this code instead of the 11900? it pays more........
 
Good point... you could...

But here's the issue, I have...

96405 is appropriate 5-FU, but not the Kenalog.

Since they are combined together what do you do?

I guess you could using the code that describes the more extensive procedure (96405) since 90% of the injectable is 5-FU. No different than injecting ONLY 5-FU.

The carrier may come back and not like it, but you may have a good defense.


I edited my previously reply.
 
AmandaF said:
My physician injects a mixture (9:1) of 5 FU and Kenalog-40 total is usually 0.3-1cc into scars or chalazions. Would the medications be billed separately with the J3301 Kenalog and J9190 for 5 FU? And would you do the interlesional or sub-q injection code?
Thanks for your help.
Click to expand...
I found this information on the CMS site; hope it helps

CPT codes 11900-11901 describe intralesional injections of non-chemotherapeutic agents. CPTcodes 96405-96406 describe intralesional injections of chemotherapeutic agents. Twointralesional injection codes shall not be reported together unless separate lesions are injectedwith different agents, in which case modifier 59 or XS may be used. It is a misuse of CPT codes11900, 11901, 96405, or 96406 to report injection of local anesthetic prior to another procedureon the lesion(s). Some of the procedures with which CPT codes 11900, 11901, 96405, and 96406are not separately reportable if the intralesional injection is a local anesthetic include:
 
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