WIXLIB

Effective Use of ‘J-codes’in Pharmacy BillingWhat are J-codes?Converting HCPCS/CPTunits to NDC unitsInformation for billingunlisted J-codeCode Glossary

What are J-codes?Healthcare Common Procedure Coding System (HCPCS) is based upon CPT(Current Procedural Terminology). It was developed by the CMS (Centers forMedicare and Medicaid) for the same reasons that the AMA (American MedicalAssociation) developed CPT i.e. for reporting medical procedures and services.Till 1996, using HCPCS was optional. But after HIPAA (Health Information Portabilityand Accountability Act), that was passed by the government later that year, itmade the use of HCPCS mandatory in certain cases.Today, HCPCS codes are used by coders to represent medical procedures toMedicare, Medicaid and other third-party payers. These HCPCS codes aredivided in three levels. Level I HCPCS codes are identical to CPT codes.Level II HCPCS codes were designed to represent non-physician services likemedical equipments, ambulance rides, wheelchairs, walkers and other medicalservices that do not fit into Level I. While CPT describes the procedure performedon the patient, it does not have codes for the products used in the procedure.HCPCS Level II codes take care of these products and pieces of medicalequipments.Level II codes are alphanumeric. Here an alphabet occupies the first character ofthe code. Similar to ICD and CPT, these codes are in numeric order and aregrouped together by the services they describe.

Types of Level II codesThe letter used as the first character has the following meaning:A-codes:For transportation, medical & surgical suppliesB-codes:For enteral and parenteral TherapyC-codes:For temporary hospital outpatient prospective payment systemD-codesFor dental proceduresE-codes:For durable medical equipmentG-codes:For temporary procedures and professional servicesH-codes:For rehabilitative servicesJ-codes:For drugs administered other than oral method, chemotherapy drugsK-codes:For temporary codes for durable medical equipment regional carriersL-codes:For orthotic/prosthetic proceduresM-codes:For medical servicesP-codes:For pathology and laboratoryQ-codes:For temporary codesR-codes:For diagnostic radiology servicesS-codes:For private payer codesT-codes:For state Medicaid agency codesV-codes:For vision/hearing services‘J’ codesThese codes include the majority ofthose drugs and biological thatshould be reported with infusions,injections and supply codes and gohand in hand with CPT procedurebased coding. In other words, Jcodes are identifiers that are used toallow pharmacy vendors,physicians, hospitals and otherpharmacy distributors to billmedications that are considered tobe a Medicare Plan B drug and areadministered in the physician office.

Converting HCPCS/CPT Units to NDC UnitsFor filling out the claim to bill for a drug, you will require thefollowing information: HCPCS/CPT code HCPCS/CPT code description Number of HCPCS/CPT units NDC (11-digit billing format) NDC description NDC unit of measure Amount of drug to be billedConsider the following example for Ciprofloxacin IV 1200MG (1 day supply):Amount of drug to be billed: 1200 MGCPT/HCPCS code: J0744CPT/HCPCS code description: Ciprofloxacin, for intravenousinfusion, 200 MGNumber of CPT/HCPCS units 6NDC (11-digit billing format): 00409-4765-86NDC description: Ciprofloxacin IV SOLN 200 MG/20 MLNDC unit of measure MLCalculate the NDC unitsYou may use an online NDC unit Calculator ToolORCalculate the NDC Units Manually: Using the aboveexampleThe amount of the drug to be billed is 1200 MG, whichis equal to 6 HCPCS/CPT units.The NDC unit of measure for a liquid, solution orsuspension is ML; therefore, the amount that needs tobe billed must be converted from MG to ML.According to the NDC description for NDC 004094765-86, In 20 ML of solution, there is 200 MG ofciprofloxacin i.e. 200 MG/20 ML.Divide the amount to be billed (1200 MG) by thenumber of MG in the NDC description, which is, 200MG. So, 1200 200 6Multiply the result number 6 by the number of ML in theNDC description which is 20 ML, to arrive at the correctnumber of NDC units to be billed on the claim that is,120 (6 x 20 ML 120)

Information required for billing unlisted J-codeDid you know more than 50% of National Drug Code (NDC)numbers have either an assigned Healthcare CommonProcedure Coding System (HCPCS) code or an assignedCurrent Procedural Terminology (CPT) code?CPT codes are referred to as Level I codes. They aremaintained by the American Medical Association (AMA).These codes are numerical and comprise of five (5)characters in length. For example - 99211, 30520 etcHCPCS codes are referred to as Level II codes. These aregoverned by the American Hospital Association (AHA) andthe Center for Medicare and Medicaid Services (CMS).Level II codes comprise of one alphabet and four numbersand similar to Level I they are also five characters in length.For example - J1950, J9217, etcIn most of the cases, NDC numbers are assigned with a Level Ior Level II code. Most of the injected medications begin with a‘J’ alphabet, but this is not always the case. It is important tosubmit claims with the most accurate information while billingfor any medication.Unlisted J-Code (example J3490):If a claim is submitted using an unlisted J-Code such as J3490and a valid CPT/HCPCS code exists for the drug beingadministered, the claims are denied and the provider needsto resubmit them using the correct CPT/HCPCS code.If a claim is submitted with an unlisted J-Code (e.g. J3490)and there is no other CPT/HCPCS code for the drug beingadministered, the provider needs to provide the followinginformation to properly process the claim:NDC NumberDrug NameDosage administered (example 5 mg, 10mg, 100mg etc.)How the number of units being billed on the claim isbeing administered (e.g. 5 mg 1 unit, 10 mg 5units, etc.)Strength of drug (example 25 mg/ml or 10 mg/10 mletc.)Single dose or Multi-dose vialRemember, an NDC number will be reimbursed for amaximum of two years after which it becomes obsolete.

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth.RequiredAbilify NOActemraJ3262DISEASE-MODIFYING ANTIRHEUMATIC AGENTSYESActhar HP J9042ONCOLOGYYESAldurazymeJ1931ENZYME DISORDER - HURLERNOAlferon 215PSORIASISNOAralast NPJ0256ALPHA 1 - PROTEINASE INHIBITORNOAranespJ0881BLOOD MODIFIER - EPOYESAranespJ0882BLOOD MODIFIER - EPOYES

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior ESBerinertJ0597COMPLEMENT INHIBITORSYESBotoxJ0585NEUROMUSCULAR BLOCK COLOGYNOCerezymeJ1786ENZYME DISORDER - GAUCHERS DISEASENOCimzia vialsJ0717DISEASE-MODIFYING ANTIRHEUMATIC AGENTSYESCinryzeJ0598COMPLEMENT INHIBITORSYESCyramzaJ9999ONCOLOGYYESCytovene IVJ1570ANTI-VIRALNODacogenJ0894ONCOLOGYNO

Code Glossary for Specialty PharmacyDrug NameDrug CategoryHCPCS/CPT CodeMedical Prior Auth.RequiredDysportJ0586NEUROMUSCULAR BLOCK AGN-NEUROTNOElapraseJ1743HUNTERS SYNDROMENOElelysoJ3060ENZYME DISORDER - GAUCHERS DISEASEYESEligard IMJ9217LHRH E-MODIFYING ANTIRHEUMATIC AGENTSYESEpogenJ0885BLOOD MODIFIER - EPOYESEpogenJ0886BLOOD MODIFIER - EPOYESepoprostenol (Flolan, Veletri)J1325PULM HYPER AGENTSYESepoprostenol (Diluent)S0155PULM HYPER OGYYESEuflexxaJ7323VISCOSUPPLEMENTSNO

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. RequiredEyleaJ0178MACULAR DEGENERATIONNOFabrazymeJ0180ENZYME DISORDER - FABRYSNOFactor Vlla - NovoSeven RTJ7189ANTIHEMOPHILIC OGYYESGammagard LiquidJ1569IMMUNE SERUMSNOGamunex C90284IMMUNE HyalganJ7321VISCOSUPPLEMENTSNO

Code Glossary for Specialty PharmacyHCPCS/CPT CodeDrug NameDrug CategoryMedical Prior Auth. RequiredHycamtin TSNOIlaris (Caremark, CuraScript)J0638CAPSNOImmune Globulin - Cytogam90291IMMUNE SERUMSNOImmune Globulin - CytogamJ0850IMMUNE SERUMSNOImmune Globulin - IM90281IMMUNE SERUMSNOImmune Globulin - IM90371IMMUNE SERUMSNOImmune Globulin - IM90389IMMUNE SERUMSNOImmune Globulin - IMJ1460IMMUNE SERUMSNOImmune Globulin - IMJ1560IMMUNE SERUMSNOImmune Globulin - IV90283IMMUNE SERUMSNOImmune Globulin - IVJ1459IMMUNE SERUMSNOImmune Globulin - IVJ1556IMMUNE SERUMSNOImmune Globulin - IVJ1561IMMUNE SERUMSNOImmune Globulin - IVJ1566IMMUNE SERUMSNO

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. RequiredImmune Globulin - IVJ1568IMMUNE SERUMSNOImmune Globulin - IVJ1569IMMUNE SERUMSNOImmune Globulin - IVJ1572IMMUNE SERUMSNOImmune Globulin - IVJ1573IMMUNE SERUMSNOImmune Globulin - IVJ1599IMMUNE SERUMSNOImmune Globulin - RhoD90384IMMUNE SERUMSNOImmune Globulin - RhoD90385IMMUNE SERUMSNOImmune Globulin - RhoD90386IMMUNE SERUMSNOImmune Globulin - RhoDJ2788IMMUNE SERUMSNOImmune Globulin - RhoDJ2790IMMUNE SERUMSNOImmune Globulin - RhoDJ2791IMMUNE SERUMSNOImmune Globulin - RhoDJ2792IMMUNE SERUMSNOIntron A 07ONCOLOGYNO

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. yprolisJ9047ONCOLOGYYESLeukineJ2820BLOOD MODIFIER - CSFNOLucentisJ2778OPTHAMOLOGYNOLumizymeJ0221ENZYME DISORDER - POMPES DISEASENOLupron Depot IMJ1950LHRH AGONISTNOLupron Depot IMJ9217LHRH NE THERAPYNOMarqiboJ9371ONCOLOGYYESmitoxantrone (Novantrone)J9293ONCOLOGYNOMozobilJ2562BLOOD MODIFIER - GCSFMNO

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. RequiredMyoblocJ0587NEUROMUSCULAR BLOCK AGN-NEUROTNOMyozymeJ0220ENZYME DISORDER - POMPES DISEASENONaglazymeJ1458ENZYME DISORDER - MPSNONeulastaJ2505BLOOD MODIFIER - GCSFNONeumegaJ2355BLOOD MODIFIER - PLTNONeupogenJ1442BLOOD MODIFIER - OD MODIFIER - PLTNOOrenciaJ0129DISEASE-MODIFYING ANTIRHEUMATIC ANALGESICNOProcritJ0885BLOOD MODIFIER - EPOYESProcritJ0886BLOOD MODIFIER - EPOYES

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. RequiredProcritQ4081BLOOD MODIFIER - SISYESProvenge (limited)Q2043ONCOLOGYYESQutenzaJ7335NEUROPATHIC PAINNORemicadeJ1745DISEASE-MODIFYING ANTIRHEUMATIC AGENTSYESRemodulin (Accredo, Caremark, CuJ3285PULM HYPER EDING-FIBRINOGEN DEFICIENCYNORisperdal Sandostatin LARJ2353SOMATOSTATIC AGENTSNOSimponi Aria (ASD Healthcare, BesJ1602DISEASE-MODIFYING ANTIRHEUMATIC AGENTSYESSolirisJ1300ENZYME DISORDER - PNHYESSomatulineJ1930GH SUPRESSIONNO

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. UPPLEMENTSNOSupprelinJ9226ONCOLOGY - OSynvisc OneJ7325VISCOSUPPLEMENTSNOTemodar ONCOLOGYNOTrisenoxJ9017ONCOLOGYNOTysabriJ2323MS - IVYES

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. HAMOLOGYNOVivitrolJ2315OPIOD ANTAGONISTSNOVprivJ3385ENZYME DISORDER - GAUCHERS DISEASENOXeominJ0588NEUROMUSCULAR BLOCK UPUYTRENS GYYESZaltrapJ9400ONCOLOGYYESYES

Code Glossary for Specialty PharmacyDrug NameHCPCS/CPT CodeDrug CategoryMedical Prior Auth. RequiredZemaira (Accredo, Coram)J0256ALPHA 1 - PROTEINASE INHIBITORNOZoladexJ9202ONCOLOGYNOzoledronic acid (Reclast)J3489OSTEOPOROSISNOzoledronic acid (Zometa)J3489ONCOLOGYNOAs Updated: June 26, 2014Miscellaneous CodesJ3490 : Unclassified Drugs and InjectionsJ3590 : Unclassified BiologicsJ7199 : Hemophilia Clotting Factor, Not otherwise classifiedJ7599 : Immunosuppressive drug, not otherwise classifiedJ7699 : NOC drugs, Inhalation solution administered thru DMEJ8499: Oral drug, (Non Chemo therapeutic)J8999: Oral ChemotherapeuticJ9999 : not otherwise classified, antineoplastic drug

4625 Morse RD., Suite 208, Gahanna, Ohio 43230info@medicalbillersandcoders.comFax: 888-316-4566Toll Free: 888-357-3226

Jun 26, 2014 · and a valid CPT/HCPCS code exists for the drug being administered, the claims are denied and the provider needs to resubmit them using the correct CPT/HCPCS code. If a claim is submitted with an unlisted J-Code (e.g. J3490) and there is no other CPT/HCPCS code for the drug being