CPT code J3490 - important guildelines and tips

I am not getting paid when I submit HCPCS code J3490 with the drug name and NDC number. Why?

Answer: 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 numbe

J3490 (Not Otherwise Classified (NOC) HCPCS Code): Billing Tips

Recently, Wisconsin Physicians Service (WPS) Medicare Part B received an inquiry regarding the use of HCPCS code J3490 (a Not Otherwise Classified (NOC) Code). The following are tips to help you when billing J3490.

In order for WPS Medicare to correctly reimburse NOC J3490, providers must indicate the following in the electronic narrative, line level 2400 loop NTE segment, or Item 19 of the CMS-1500 form:

The name of the drug,

The total dosage (plus strength of dosage, if appropriate), and

The method of administration; and

List the units of service as one in 2400/SV1-04 data element of the ANSI X12 4010A1 or in item 24G of the CMS 1500 form. As you may know, pricing for NOC J-codes is determined by the information provided on the Average Sales Price (ASP) NOC pricing file. If the ASP NOC file lists the strength for a drug on the file, this indicates that the drug comes in different strengths. Medicare payment varies depending on the strength given. 

In this situation, providers should list the name of the drug, strength of the drug, the amount of the drug administered and the method of administration.

When billing Medicare for a NOC J-code, you can determine if the drug comes in different strengths by accessing the ASP NOC pricing files. You can access the files on the Centers for Medicare & Medicaid Services (CMS) website

How should I submit compounded drugs administered via implanted pump?

Answer:

Submit a single, combined line item for all drugs with HCPCS code J3490. Combine the charges for all drugs. 

Electronic claims: 

Indicate the name(s) and dose(s) of each drug being submitted in the documentation record

Paper claims: 

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).

Medicaid - Billing Unclassified HCPCS Codes

Physician Office

• 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.

Example:

– J3590 Unclassified biologics

– J3490 Unclassified drugs

• Additional information required in Box 19 will vary by payor

Hospital Outpatient 

• Bill on the UB-04/CMS-1450 or electronic equivalent.

Example:

– J3590 Unclassified biologics

– J3490 Unclassified drugs

• Additional information required in Field 80 (Remarks) will vary by payor

Medications Approved to Bill HCPCS J3490

Billing instructions: For services billed using J3490, all claims are billed as paper claims and must include the NDC, the drug name and strength, and cost invoice where applicable. 

J3490 Notice Coding Alert

Coding Alert: J3490 Billing, Unclassified Drugs

A number of members have contacted APMA with questions regarding recent marketing they have received describing single-use injection kits. The marketing pieces suggest that providers who typically are not reimbursed for their local anesthetic supply and/or therapeutic medication supply consider purchasing bundled injection kits, and bill the use of kit material under a single J3490 - unclassified drug(s) HCPCS code.

APMA has also heard from several payer medical directors who have expressed concern regarding this billing practice. The medical directors have noted the use of these kits to get around policy non-payment for the local anesthetic supply would be deemed to be "an abusive billing practice." They mentioned that they have initiated a process to stop payment when these codes are submitted.

Some Medicare contractors have published policies regarding the requirements for billing J3490. The following is an excerpt from First Coast Service Options' directive for those billing J3490:

When billing J3490 – unclassified drugs – the provider must indicate the name, strength, and dosage of the drug(s) in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in the ANSI 837 claim file).

Some commercial payers also have payment guidelines defining the billing of J3490. The following is sample language from Blue Cross Blue Shield of Illinois:

If a claim is submitted using an unlisted J-Code (e.g. J3490) and a valid CPT/HCPCS code exists for the drug being administered, BCBSIL will deny the service line and request that you resubmit the claim 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 administered, you need to provide the necessary information on the claim for BCBSIL to properly adjudicate the service line. 

If the claim is received without the necessary information, the service line may be denied and sent back to you with a request to resubmit the service along with the necessary information.

We need the following information to process valid unlisted J-Codes:

• NDC Number
• Drug Name
•  Dosage administered (e.g. 5 mg, 10 mg, etc.)
• Include how the number of units being billed on the claim is being administered (e.g. 5 mg=1 unit, 10 mg=5 units, etc.)
• Strength of drug administered (e.g. 25 mg/ml, 10 mg/10 ml, etc.)
• Single dose vial or Multi-dose vial

If you are considering using and billing for injection kits, it is recommended that you contact the payer in question to find out if they have policies or guidelines in place for the billing of J3490 – unclassified drug(s).

Please note: 

The new compounded drug code, Q9977 - Compounded Drug, Not Otherwise Classified, is not a replacement for existing codes. It is intended to distinguish compounded drugs (which may include biologicals) from other “not otherwise classified” codes such as J3490, J3590, J7799, J9999 and existing specific codes for compounded nebulized drugs. 

The implementation of Q9977 as a means of identifying compounded drug claims does not affect existing payment policy for compounded drugs as outlined in the “Medicare Claims Processing Manual,”