need coding help for pump refills

[Doctodd]

As title says, i need some help with making this work in my office. I did a marcaine/dilaudid pump refill on a patient. I need help with the codes for the meds....i paid for his meds, which were about $95. The refill kit from Medtronic costs $28. So i bill 99214, 95991 for refill, and i think i forgot but i should have added 62368....dont hold me to that one. What are the codes that i should use to bill for the meds, and the kit if possible?

The reason im worried is cuz i did a reprogramming on a Baclofen pump patient, and used 99214 and 62368....they deny 99214 cuz they say it is a surgical procedure and the visit is included as per my contract. The reimbursement was $31....LESS THAN HIS COPAY OF $40. This is Cigna by the way.

Any help with how i can make this work in my office is appreciated.....especially the J code for the marcaine/dilaudid that cost me $95.

thx and make it a great day

T

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[Doctodd]

update while opening some EOB's today.....the patient who i refilled with Marcaine/Dilaudid...i was paid by BCBS for 62368 while inpatient $33.59. But i think we billed it incorrectly with the new software so dont hold me to that number yet. But still a good estimate.....not what i was expecting, especially since i havent billed for the meds yet. Waiting on you guys...;-)

T

 

[Tenesma]

pump refills are an issue because medicare and a lot of the insurance companies will only reimburse the actual cost of the drug and not allow you to mark it up - so unless some of you guys have figured a way around it there is really no way to make any profit off the drugs themselves

you really shouldn't be mixing an E&M code with a refill unless you actually provided all the components of an E&M visit (and documented them on a separate form) and the modifier would be 25 for whichever E&M you use

the re-programming ends up paying a bit better (that is if it is a real programmable pump as opposed to a Codman pump)

95991 is the right code - but pays about $35 (if inpatient or hospital as opposed to about $85 for office-based)... and sometimes payers will delay or deny the medications/kits etc.... so it can actually become a money loser.

a lot of the guys who still do pump refills require the patients to show up with the medication and the refill kits (patients then are the ones dealing with the purchases/reimbursements) and they do the refills - most of those patients seem to be perfectly fine with it because they are just happy to have found somebody who will do their pumps...

i remember there was a guy in florida who had crazy clonidine combos for his pumps because he had figured out that certain companies were paying per microgram and was averaging about 3k per refill!!! of course that loophole was quickly closed...

 

[Doctodd]

thx Tenesma.....i might do that....have the patient bring in the meds himself. But im not interested in a markup as much as im interested in getting the meds paid for. So can anyone provide me with the J-code?

thx

T

 

[Disciple]

thx Tenesma.....i might do that....have the patient bring in the meds himself. But im not interested in a markup as much as im interested in getting the meds paid for. So can anyone provide me with the J-code?

thx

T

I believe it's J1170 (Dilaudid) with KD modifier. May want to double check that.

 

[Doctodd]

thx a ton....checking this out.

T

 

[mehul_25]

Can refills be done at an ASC? If so, do they need to be billed specially?

 

[PAINBILLER]

Since it is a compound drug, you will need to bill under J3490. We add a 15% handling fee above the invoice price since we have to do the ordering, cut the check to the compound pharmacy, etc. and we have not had problems with this since it is a reasonable charge. I would bill your scenario the following way to Cigna:

95991
J3490 $109.25 ($95 x15%)
62368
A4220

You can indicate in Box 19 "compound drug, see attached invoice for details" and then attach report and invoice to the claim.

 

[Mister Mxyzptlk]

Looks like you were billing wrong, T. I wonder if this is why so many people think refilling pumps is not worth doing? Is everyone using 95991, 62368, and A4220? Even though Medicare thinks you get your kits for free and bundles A4220 it still pays more than a level 4 office visit.

 

[Ligament]

Since it is a compound drug, you will need to bill under J3490. We add a 15% handling fee above the invoice price since we have to do the ordering, cut the check to the compound pharmacy, etc. and we have not had problems with this since it is a reasonable charge. I would bill your scenario the following way to Cigna:

95991
J3490 $109.25 ($95 x15%)
62368
A4220

You can indicate in Box 19 "compound drug, see attached invoice for details" and then attach report and invoice to the claim.

I was not aware Noridian would pay a handling fee! WPS (midwest Medicare carrier) has only been paying invoice price. This is good to know.

It is important to note that if you are having the nurse, PA, or NP perform the refill, you have to use 95990- code 95991 is defined as "administered by physician".

Can refills be done at an ASC? If so, do they need to be billed specially?

As far as I can tell, the Medicare 2008 fee schedule for ASCs does NOT list 95991. I could be wrong- maybe someone else has experience with pump refills in ASC?

Other info on pump billing in this thread
Hydromorphone/marcaine billing codes pump refill
http://forums.studentdoctor.net/showthread.php?t=473037

 

[PAINBILLER]

We were pleasantly surprised by Medicare covering our handling fee as well. The guidelines do state that they cover 106% of the average wholesale price (AWP) but I have never had any luck finding any information regarding the "wholesale price". I have to assume that our invoice times the 15% apparently meets or is under the 106% which is why it is being paid.

 

[Doctodd]

awesome work....i will try this

 

[stim4u]

I appreciate the billing info..

can you please give examples for billing for dilaudid and morphine, and number of units billed.

For example how would you bill 10mg/ml Morphine, 20ml total volume used?

thanks in advance.

 

[PAINBILLER]

Assuming these are not compounded meds:

Morphine 10mg/ml J2275 (preservative free, sterile solution) x 10 units

Dilaudid 10mg/ml J1170 x 50

 

[Doctodd]

is A4220 the medtronic refill kit?....how much are you charging for this?

T

 

[PAINBILLER]

To carriers other than Medicare we charge $20.00.