I am not getting paid when I submit HCPCS code J3490 with the drug name and NDC number. Why?
HCPCS code J3490 is a non-specific code that should be used only when another 'J' code does not describe the drug being administered (i.e., CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug.
For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code). If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490.
If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.
How should I submit compounded drugs administered via implanted pump?
Submit a single, combined line item for all drugs with HCPCS code J3490. Combine the charges for all drugs.
- Indicate the name(s) and dose(s) of each drug being submitted in the documentation record
- Indicate 'compunded drugs, invoice attached' in Item 19 of the CMS-1500 Claim Form
- Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)
- Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g., INV $250.00).
Example of information required to accompany an unclassified drug:
Bupivacaine, 0.50% 1ml
*Two decimals. NDC quantity is based upon the numeric quantity administered to the patient based upon the unit of measurement (AWPU). The standard unit of measurement (UOM) codes are:
F2 = International Unit
ML = Milliliter
UN = Unit
J3490 Unclassified drugs
National Drug Codes Associated With Procedure Code J3490 to Change for Texas Medicaid
Note: The Health and Human Services Commission (HHSC) has requested that TMHP publish the following information:
National Drug Codes (NDC) associated with procedure code J3490 (Unclassified drugs) will change for Texas Medicaid beginning with date of service on or after February 15, 2016.
The Health and Human Services Commission (HHSC) completed a review of drugs and products associated with procedure code J3490. As a result, HHSC identified NDCs that were inappropriately billed using procedure code J3490.
The Texas NDC-to Healthcare Common Procedure Coding System (HCPCS) Crosswalk released February 15, 2016, will reflect the end-date of NDCs for use with procedure code J3490.
Medicaid - Billing Unclassified HCPCS Codes
• Bill on the CMS-1500 or electronic equivalent
• Example HCPCS J3590 or J3490
• NDC is required on Medicaid claims including the paper CMS-1500, electronic 837P Web electronic 837P, Web interChange interChange claims and Medicare crossover claims
–Reporting instructions vary by payor
Private Payors - Billing Unclassified HCPCS Codes
• Bill on the CMS-1500 or electronic equivalent.
– J3590 Unclassified biologics
– J3490 Unclassified drugs
Additional information required in Box 19 will vary by payor
• Bill on the UB-04/CMS-1450 or electronic equivalent. Example:
- J3490 Unclassified drugs
Physician Office: Sample CMS-1500
Hospital Outpatient: Sample UB-04
Medicaid Billing – Rules for J3490/Suboxone®/Buprenorphine in Hubs
Medicaid billing follows the protocol developed by the Division of Vermont Health Access (DVHA). Please note any DVHA issued document outlining Medicaid billing protocols after the date of this document will supersede these instructions.
1. Billing providers are limited to those on this list:
Start date of service 01/01/2013 - Howard Center NPI 1134346687
Start date of service 03/01/2013 - Howard Center NPI 1093005092
Start date of service 03/01/2013 - BAART (NEK) Location NPI 1902944002/Taxonomy 261QM2800X
Start date of service 07/01/2013 - BAART Central Vermont Location NPI 1225115439
Start date of service 07/01/2013 - HABIT OPCO (West Lebanon) NPI 1023175072
Start date of service 07/01/2013 - HABIT OPCO (Brattleboro) NPI 1912155516
Start date of service 10/01/2013 - Rutland Regional Medical center NPI 1467416206/Taxonomy 261QM2800X
2. “Suboxone” or “Buprenorphine” must be written in field 19 of the CMS-1500 claim form or in the electronic claim notes field.
3. One of the diagnosis codes for the J3490 detail must be 304.00 – 304.03.
4. Use HCPCS code J3490 - UNCLASSIFIED DRUGS. Do not use a modifier with this code as that will cause the claim to deny.
5. From the Provider Manual:
When entering an NDC on your claim form, please enter the following data elements in the following order: NDC, measurement qualifier code and unit quantity. Do not insert brackets, spaces or dashes. Claims formatted incorrectly will be denied.
FL 24D: HCPCS code
FL 24D Shaded area: 11 digit NDC number, Unit of Measurement Qualifier, and Unit Quantity
Suboxone® for Uninsured Clients
There is very limited funding for Suboxone® for uninsured patients. Because of the high cost of the drug, it is unlikely that most individuals can afford to continue Suboxone® treatment when transferred to a spoke. At present, Medicare will not pay for Suboxone® provided in a hub but may pay for it when prescribed in a spoke so Medicare clients are the most appropriate use of available funds.
Providers must have a mechanism in place to assist clients in accessing insurance coverage through the Exchange to minimize the portion of uninsured clients in the hubs.
Only those providers able to bill Medicaid for Suboxone® using the J3490 code are eligible to receive funding for Suboxone® for uninsured individuals. Providers are limited to the Medicaid covered NDC codes and doses. The price per unit for Suboxone® for uninsured is the same as the Medicaid rate.
The total grant amount for Suboxone® is included in the hub grants. In order to support the use of the funding, a report of the actual cost of Suboxone® provided to uninsured patients is to be submitted quarterly.
HCPCS and CPT Codes for OPDIVO® (nivolumab)
*CPT codes and descriptions only are © 2014 by American Medical Association (AMA). All rights reserved. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.
Please contact the payer or BMS Access Support® for additional coding information regarding OPDIVO.
HCPCS codes for physician offices
• Following FDA approval of new physician-administered therapies, physician providers may need to use temporary codes until unique drug codes are assigned
• J9999 is the most commonly used “not otherwise classified” (NOC) code for anticancer therapies4
• J3590 may also be used, and J3490 may be used in rare cases4,5
• When submitting an NOC claim using HCPCS code J9999 (J3490 or J3590), include specific information in Box 195,6:
— The drug name (chemical name)
— Total dosage and strength
— Method of administration
— Prescription number (11-digit NDC)
— Basis of measurement (mg, units, etc)
• Payer requirements for coding of newly approved therapies may vary. Please contact the payer or BMS Access Support® for additional coding information