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Billing Medicare For Denial For Infusion Claims Feb 2012

Believe it or not, not all denials are “Bad” denials; at times you will be seeking to obtain a “Good” denial from Medicare. Without the correct denial reason from Medicare you will not be able to bill and collect payment from the secondary insurer or, in some cases, the patient.  Accurate billing of Medicare for denial is just as important as billing Medicare for payment. There are several services that Medicare considers “non-covered services”. These include but are not limited to many antibiotics, hydration, catheter care and other infusion services.  Additionally, if the patient does not meet Medicare coverage criteria, providers must bill Medicare for denial.  The following scenarios are cases in which your goal is to obtain a good denial from Medicare for some home infusion services:

  • Drug is not administered with a durable infusion pump. (i.e. service is drip infusion or given via elastomeric or other disposable infusion pump.)
  • Drug is administered with a durable infusion pump.

Scenario #1

Guidelines for submitting a claim for denial when drug is not administered with a durable infusion pump are as follows:

  • DIF(DME Information Form) is not required
  • ABN (Advance Beneficiary Notice) is not required

Supplies

  • Code A4223 (Infusion supplies per cassette or bag)
    • Modifier is not required
  • Code A4221 (Supplies for maintenance of a drug infusion catheter per week if the patient has a catheter)

Drugs

  • The actual drug HCPCS code must be used for drugs with specific codes.  (You can find a useful crosswalk from the NDC to the HCPCPS on www.dmepdac.com.) 
  • J3490 ( Use this code when there is no specific code for the drug dispensed)
    • A description of the drug and dosage must be entered on the claim
  • GY Modifier – include for drugs that are not eligible for coverage under the Medicare benefit. 
    • An explanation must be entered on the claim (i.e. not administered with a durable infusion pump)

Scenario #2

Guidelines for submitting a claim for denial when drug is administered with a durable infusion pump are as follows:

  • DIF is required
  • ABN is required – (If an ABN is not obtained, claim is submitted with a different modifier)

Supplies

  • Code A4221 (supplies used for maintenance of drug infusion catheter per week – if the patient has a catheter)
  • Code A4222 (infusion supplies used with and external infusion pump -  per cassette or bag
  • GA Modifier is added if ABN was obtained
  • GZ Modifier is added if no ABN was obtained

Drugs

  • The actual drug HCPCS code must be used for drugs with specific codes.  (You can find a useful crosswalk from the NDC to the HCPCPS on www.dmepdac.com.) 
  • J7799 ( Use this code when there is no specific code for the drug)
    • Name of the drug and indications for use must be entered on the claim.
  • GA Modifier is added if ABN was obtained
  • GZ Modifier is added if no ABN was obtained

Equipment

  • The actual E code of the external infusion pump is used.
  • GA Modifier is added if ABN was obtained.
  • GZ Modifier is added if no ABN was obtained.

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