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May 18th, 2020
Packaging and Units for Billing Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 18th, 2020
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
Clarify the Complexity Please! NDC Codes and Drug Classification Systems
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...
2020 Medicare Part D Coverage Gap (AKA donut hole)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 26th, 2020
Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2019
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
Medicare sent out a news release to inform of incorrect reimbursement and correction.
"End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they:
Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and
Contain non-covered charges
After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
Understanding The Healthcare Fraud Prevention Partnership's Commitment to the Management of Opioid Misuse and Opioid Use Disorder
By Jared Staheli | Published February 27th, 2018
The opioid epidemic continues to ravage communities nationwide. Since 1999, opioid deaths have quadrupled. 91 Americans die every day from opioid overdoses, and these numbers show no signs of declining. To address an epidemic of this magnitude, unprecedented cooperation between all involved parties needs to occur. In January 2017, CMS released a ...
Dental and Medical- Controlled Substance Awareness
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2018
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
By Wyn Staheli, Director of Research | Published January 25th, 2018
Prescription drugs can be quite costly for those who are uninsured or underinsured. Prohibitive costs have been shown to lead to poor patient outcomes because medications are not taken as prescribed. Medicare has taken steps to address this problem with their Medicare Advantage value based plans (see referenced "Medicare Expands Value ...
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
This is a list of some of the most common Injectable unclassified drugs used with J3490
Antilirium – 1 mg/ml
Ascorbic Acid – 500 mg/ml
Ascorbic Acid – 250 mg/ml
Bacitracin, Intramuscular – 50,000 unit vials
Bacitracin, Intramuscular – 10,000 unit vials
Brevital Sodium – 500 mg/5 ml
Caffeine and Sodium Benzoate – 250 mg/ml
Capastat Sulfate – 1 ...
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
By Brittney Murdock, QCC, CMCS, CPC | Published December 16th, 2016
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
Product Wastage Documentation Requirements and Reporting: Using JW Modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ...
Pass-Through Payments, how they work and Device Category Codes List
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 4th, 2017
If you want to know if a DRUG is a Pass through drug - Find-A-Code has that information on the code information page under FEES and APC Fee information
A pass through payment for a drug is Medicare reimbursement paid in addition to an ASC's facility fee, however, CMS limits the eligibility ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 25th, 2016 - Last Review/Update August 7th, 2017
Single Drug Pricer (SDP): Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present, SDP includes the HCPCS Drug pricing file.
Part B Drug pricing is the payment amounts that will be used to pay for Part B covered drugs. The payment ...
The JW Modifier is Only Applied to the Amount of Drug or Biological that is Discarded
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 19th, 2015 - Last Review/Update August 4th, 2017
According to CMS, local contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological.
For example, ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Pharmacy compounding is a has been done for many years, it is a tradition that offers customized care to meet the specific needs of individual patients. Modern technology and innovative techniques with research have allowed more pharmacist to customize medication to meet a patients needs.
Through compounding, a prescriber and pharmacist can adjust ...
Exceptions to Average Sales Price (ASP) Payment Methodology (Rev. 2437, 01-01-13) Medicare Pub 100-04 Drugs and Biologicals
By Jared Staheli | Published July 8th, 2015
The payment allowance limits for blood and blood products (other than blood clotting factors) that are not paid on a reasonable charge or prospective payment basis, are determined in the same manner the payment allowance limits were determined on October 1, 2003. Specifically, the payment allowance limits for blood and ...
Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present.
On a quarterly basis, CMS furnishes three SDP files to all FIs, carriers, and ROs except regional home health intermediaries (RHHIs) and durable medical equipment regional carriers (DMERCs), as follows:
1. ...
HCPCS Service Coding for Oral Cancer Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
The following codes may be used for drugs other than Prodrugs, when covered:
Generic/Chemical Name
How Supplied
HCPCS
Busulfan
2 mg/ORAL
J8510
Capecitabine
150mg/ORAL
J8520
Capecitabine
500mg/ORAL
J8521
Methotrexate
2.5 mg/ORAL
J8610
Cyclophosphamide *
25 mg/ORAL
J8530
Cyclophosphamide *
(Treat 50 mg. as 2 units
50 mg/ORAL
J8530
Etoposide
50 mg/ORAL
J8560
Melphalan
2 mg/ORAL
J8600
Prescription Drug chemotherapeutic NOC
ORAL
J8999
Each tablet or capsule is equal to one unit, except for 50 mg./ORAL of cyclophosphamide (J8530), which is shown as ...
HCPCS and NDC Reporting for Prodrugs (Rev. 136, 04-09-04)
By Jared Staheli | Published July 8th, 2015
FI claims
For oral anti-cancer Prodrugs HCPCS code J8999 is reported with revenue code 0636.
DMERC claims
The supplier reports the NDC code on the claim. The DMERC converts the NDC code to a “WW” HCPCS code for CWF. As new “WW” codes are established for oral anticancer drugs they will be ...
Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 131, 03-26-04)
By Jared Staheli | Published July 7th, 2015
Prior to January 1, 2004, drugs and biologicals not paid on cost or prospective payment are paid based on the lower of the billed charge or 95 percent of the average wholesale price (AWP) as reflected in published sources (e.g., Red Book, Price Alert, etc.). Examples of drugs that are ...
How do I find a HCPCS code for a laxative given to a patient in our office?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
Aug 15, 2014 - "The Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet - Revised The "Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS): Information for Pharmacies" Fact Sheet (ICN 905711) was revised and is now available in downloadable format. This fact sheet is designed to provide education for pharmacies on DMEPOS. It includes information on accreditation by a CMS – approved independent national Accreditation Organization, as well as information if a pharmacy wants to be considered for an exemption from the accreditation requirements.
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August 25th, 2020
Do You Have All the Right Dental Resources Needed to Succeed in Dental Medical Billing and Coding?
Discussion with LaMont Leavitt (CEO of innoviHealth) and Christine Taxin (Adjunct professor at New York University, President of Dental Medical Billing, and Links2Success).
Some of the resources and tools they discuss will help you with your dental coding/billing and education.
Quick, Current, Complete - www.findacode.com