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reimbursement for unlisted codes

Gina Posted Wed 09th of November, 2011 16:27:08 PM

Im am having trouble getting paid the correct amount on the new drugs Halaven & Xgeva from bcbsri. They are paying in ml instead of mg. Xgeva is 120mg per unit/1.7ml and Halaven is 1mg per unit/2ml. They want us to bill in ml instead. I explained to them that J-codes are listed as mg and mcg. Do you have any documentation that I can appeal with. Thank you.

SuperCoder Answered Thu 10th of November, 2011 07:48:26 AM


XGEVA™ is the new drug passed in Mar-2011 and there is no established CMS LCD/NCD, so it is payer to payer choice to ask for their different measurement methodology and documentation requirement.

Billing requirements for unclassified or miscellaneous codes may vary by payer; however, payers typically require providers to list drug name, dosage, and NDC number in Box 19 (or corresponding field for electronic claims) when billing with unclassified code Note: XGEVA™ is supplied as a 120 mg dose; its NDC is 55513-0730-01

Once the CMS LCD/NCD (probably from Mar 2012) will establish, the things will get resolved.

You can find following reference regarding the same.

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