Wiki J0885

[jeaner54175@yahoo.com]

Need some advise if we are coding this correctly for an outside order. We have a patient who started receiving Procrit injections at the beginning of the year along with HGB and HCT labs. Medicare has been denying payment and we found out we needed to use modifier EC with J0885, 96372 with the diagnosis 585.4, 285.1. Also we found out from billing even though we pay a large sum of money for the Procrit vials we are getting reimbursed a little over $12.00. As far as reimbursement goes would the patient's insurance (BC/BS Medicare RX) cover the cost of the Procrit if he purchased it through the pharmacy and brought it in. Any advise would be appreciated.

Thank you,
Lisa

 

[kathyle]

For my understanding, you concern that you only get pay over $12 for the procrit? Did you bill with the correct units? What is pt dose? You might want to check the unit that your office billed. If you billed with correct units then review the EOB, lot of time, payer processed with 1 unit instead of the billed unit. If that is the case, then you need to send in an appeal.
Hope my answer help.

 

[relong]

I would definately check the units billed. then I would get on CMS website and pull up the fee schedule, then I would check your purchase price per unit. Procrit used to be underwater, but reimbursement has gone up the last couple of years so most providers should be ok.

Our office doesn't allow brown bagging, but you'll have to call your patient's precription plan to find out their benefits.