J3490

[PippiT]

I need help or direction, please!

We have billed J3490 with NDC N476420076001 successfully with other procedure codes in the few instances we have billed it for the first half of last year.

In September we billed it the same as always and received a letter from the ins company that says:

The ndc submitted contains items that may not separately be reimbursed. Please resubmit the claim with the individual hcpcs code and/or the appropriate, separate ndc codes along with a copy of this explanation of payment.

Next steps:

Please send a corrected claim. Include information mentioned above.

I have submitted, resubmitted, sent letters and medical records. I get a different response every time. 4/15/16: CS rep told me I needed to replace J3490 with another J code and directed me to the website where I couldn't find any J codes to replace it.

Then on 5/5/16: a different CS rep told me it is considered a convenience kit and is not covered by the patient's benefits.

We billed it again in March 2016 for a different patient. We received the same letter for this patient as above. CS rep said they need a corrected claim because the NDC # used for the kit is not a valid code for J3490.

I am really confused. I would appreciate any insight/feedback, etc.

[kristin]

Is this a Lidolog "kit" that comes with Kenalog, lidocaine, and some other supplies in it that are used when giving a cortisone injection? The NDC # you provided seems to indicate that, as well as the rep stating it is a convenience kit.

If so, the first problem is when giving a therapeutic injection, you cannot bill for the lidocaine, only for the Kenalog. So it looks like they want you to bill for the Kenalog only, using the appropriate J code, which is J3301.

The next problem is the rest of the stuff in the kit(gloves, swabsticks, bandage, gauze) are not reimbursable, they are considered to be normal supplies used in doing an injection, and are factored into the RVU's for the injection code.

In 2015, I saw a bunch of questions about these kits, using that NDC #, on another billing site, and the consensus was that it was a scam by the manufacturers to get doctors to purchase them, and that while insurances might initially pay for them, they would eventually get smart and stop paying for them. Sure enough, that is what is happening.

I think you may be out of luck, if we are talking about those kits. The only thing payable in them is the Kenalog, which has the J code I mentioned above.

[PippiT]

Thank you very much! This makes sense. The limited google information out there I figured it was something like this. This helps me a lot. I appreciate it!

[kristin]

Happy to help!