Wiki Billing J codes for Pain Management

[tmckean2]

Good Morning All,

We just got a new client whose specialty is Pain Management. I am new with following up on payment reimbursement for this type of client. So I am a little overwhelmed. We are receiving a lot of denials for the J codes being inclusive to the procedure but I can not find anywhere that states what is inclusive. The CPT codes being billed do not state that the medicine used is included and the CPT is not listed in Appendix G of the CPT as an inclusive code. I do understand the NCCI edit on the J code J2001.

Example: CPT code 64494-50 billed with J3490.

Can someone explain this to me so that I can better understand and explain to the doctor? These are being billed to commercial insurance not Medicare.

Thank you,

 

[Pam Warren]

If the services are being provided in a hospital or other facility, and you are coding only the physicians services, then the J codes are going to be billed by the facility....not the physician. After all, the medications come from the facility, and are not provided (i.e. purchased) by the physician.You would only bill the administration codes for the physician.

 

[tmckean2]

The services are being billed in an office setting where the physician is the owner/operator.

 

[mitchellde]

The services are being billed in an office setting where the physician is the owner/operator.

J3490 is an unclassified drug code, what is the drug being used?

 

[tmckean2]

In this example it is Marcaine. I have questioned the doctor on why he is billing it under J3490 instead of S0020, but no reply yet. But in other cases it has been for other drugs that are not listed on the table in the HCPCS book. So the J code would be appropriate.

Thanks,