Transitioning to New J Code: J2787 - Avedro · [email protected] Customer Service and Account...
Transcript of Transitioning to New J Code: J2787 - Avedro · [email protected] Customer Service and Account...
Photrexa® Viscous (riboflavin 5’-phosphate in 20% dextran ophthalmic solution) &
Photrexa ® (riboflavin 5'-phosphate ophthalmic solution)
Transitioning to New J Code: J2787
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DISCLAIMER
The information provided is for informational purposes only and
represents no statement, promise, or guarantee by Avedro concerning
levels of reimbursement, payment or charges. Codes are supplied for
informational purposes only and represent no statement, promise, or
guarantee by Avedro that these codes will be appropriate or that
reimbursement will be made. Information provided is not intended to
increase or maximize reimbursement by any payor.
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• A J Code is part of the HCPCS Code Set and represents a medicinal substance for
billing and reporting purposes
• “J” codes include the majority of drugs and biologicals that should be reported with
infusions, injections, and supply codes that go hand in hand with CPT procedure based
coding used for billing and other reporting.
• HCPCS = Healthcare Common Procedure Coding System
• CPT = Current Procedural Terminology is a medical code set that is used to report
medical, surgical, and diagnostic procedures and services to entities such as
physicians, health insurance companies and accreditation organizations.
• J Codes are made up of one letter (J) and 4 numbers: JXXXX
• Unlisted codes provide the means of reporting and tracking services and procedures until a more specific
code is established.
• Miscellaneous/Unlisted J Codes must be billed with other identifying information (such as the NDC#) in
order to be affiliated with the proper drug or biologic
• Claims with Miscellaneous/Unlisted J Codes are processed manually at the payer due to the variety of
products with which it is associated
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• Unlike an unassigned or miscellaneous J Code, a dedicated J Code is permanent and typically not shared
with any other product or medicinal substance.
• The new dedicated J Code for Photrexa Viscous and Photrexa is:
J2787
Photrexa Viscous/ Photrexa Cross-Linking Kit
NDC:25357-025-03
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• Billing is based on date of the procedure regardless of the date product was purchased
• The NDC should still be reported as payers may still require an NDC to adjudicate the claim.
Product Administered 2018 Product Administered 2019
Bill using J3490 Bill using J2787
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Payers typically request the NDC entered in an 11-digit format, with an extra “0” added to the
beginning of the second section, without hyphens.
❖ 25357-025-03 would be 25357002503
❖ Payers may also require an N4- qualifier preceding the NDC.
!
• To ensure adequate reimbursement we recommend initially submitting claims with
o a copy of the purchase invoice,
o medical records, and
o the operative report to help with claims processing (for 0402T as well).
• Going forward the invoice should no longer be required.
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When billing for the Cross-
linking Kit NDC, 2 HCPCS
units may be billed in Box
24G.
Additional drug description
may be added to the shaded
portion of the line in Box 19
and 24, including the NDC, unit
of measure, and amount
administered.
CY 2019 Sample CMS 1500 Claim Form
N425357002201 Photrexa Viscous 1.46 mg/1 ml ML3
1234567890X
H18.62X
N425357002503 ML601 01 18 01 01 18 11 J2787 1 $XXXX.XX 2
01 01 18 01 01 18 11 0402T RT 1 $XXXX.XX 1
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Please Note: The information shown here is a general guideline only - actual payer and clearinghouse requirements may vary.
BOX 24B, SERVICE
Place of service code is 11 for physician office or 24 for freestanding ASC.
BOX 24D, SERVICE
CPT 0402T for corneal cross linking. HCPCS J2787 for Photrexa Viscous and Photrexa.
BOX 24E, SERVICE
Point to corresponding diagnosis code in Box 21.
BOX 24F, SERVICE
Billed charges associated with the procedure should reflect all necessary work, technical or practice expense or overhead. It is appropriate to bill separately for the drugs.
BOX 24A, SERVICE
Enter in date(s) of service.
BOX 24G, SERVICE
Bill 2 units with the Kit NDC to represent 6ML of drug because the HCPCS code description is “up to 3 ML”.
BOX 24, SERVICE – Shaded Portion of Line Item Include all details specific to drugs used for claims processing.
N4 – NDC identifier that precedes the actual NDC. Payer requirements for this vary.
National Drug Code (NDC) – Format this number to 11 digits by adding an extra “0” to the beginning of the 3-digit middle section. Payer requirements for this vary.
Unit of Measure – Photrexa Viscous and Photrexa are a physician administered drug, in drop form. The unit of measure is Milliliter or ML for a liquid, solution, or suspension.
“ML6” or Amount Used – The amount used with the Kit is 6 ML.
HCPCS code J2787 for Photrexa Viscous and Photrexa. (Riboflavin 51-phosphate,
ophthalmic solution, up to 3 ML) is effective January 1, 2019. Use this code for dates of
service on or after January 1, 2019.
National Drug Code (NDC)Most payers require this information for claims processing.➢ The NDC number for the Photrexa
Cross-linking Kit that contains the Photrexa Viscous and Photrexa in the
single use kit (separate foil pouches) is 25357-025-03.
➢ Payers typically request an 11-digit NDC . Add an extra “0” to the beginning of
the 3-digit middle section (25357002503).BOX 21. ICD-10-CM
Diagnosis code should be for keratoconusor corneal ectasia following refractive surgery.BOX 23. PA NUMBER
Enter prior authorization reference number.
Photrexa Cross-linking Kit, 25357002503, 6ML
• Process may vary by payer, we anticipate there may be variation in payers loading the
new J-code.
• For all payers ARCH will automatically request authorizations with J2787 beginning
January 1, 2019.
• ARCH will handle requests on a per case basis, based on payer guidance.
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• Payment may be affected by the provider’s contract, and the patient’s plan.
➢ Check contract language!
• Commercial payers establish their own reimbursement methodologies and
reimbursement can vary by payer.
• For example, a commercial payer may base payment on a percentage of Average
Wholesale Price (AWP).
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Example from Anthem:
AWP: $3,420 – 16% = $2,872.80
2 units= $2,872.80
1 unit = $1,436.40
1. When will the new J-code be loaded?
Most commercial payers will load the new J-code (J2787) within the first month after the effective date. Commercial payers will vary.
You may contact ARCH or your respective provider relations contact at your payers for specifics.
2. When will I be able to use the new J-code?
January 1, 2019 is the effective date. Most commercial payers will implement the effective date on January 1, or retroactively to
January 1, despite when they actually load the new code.
3. How will I know if my payers have loaded the new code?
You can contact your respective provider relations representative at your payers for specific information. ARCH and your Field
Reimbursement Manager (FRM) can help you as well.
4. How will the process for submitting claims be different?
For most payers you will no longer have to submit copies of invoices with your claims. Your claim form may need to be completed
differently regarding the how many units must be billed. (Please see previous slide for detail).
5. How much will I be reimbursed?
Reimbursement will vary from payer to payer but most use a price compendium that in most instances covers the cost of the drug plus
a small handling fee. You may contact your respective provider relations representative at your payers for specifics. ARCH and your
Field Reimbursement Manager (FRM) can help you as well.
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6. What if I bought my drug in 2018, can I still file with new J code?
The new J code should be used when the procedure is completed in 2019, regardless of the purchase date.
7. What if I treated in 2018, can I still file in 2019?
Yes. If you treated in 2018, you can file your claim for the 2018 procedure in 2019 using the old miscellaneous J Code
J3490.
8. What if I made a submission in 2018 with the miscellaneous J code and received low payment and want to
appeal. Should I still use the miscellaneous J code?
Always use the date of the procedure to determine which J code to use. If the date of the procedure was before
January 1, 2019, use the miscellaneous J code, J3490. If the procedure is completed on or after January 1, 2019,
use the new, dedicated J code, J2787
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ARCH Hotline (for questions about coding, billing,
claims submissions or payer coverage)
1-844-528-3311
Medical Information and Adverse Event Reporting(844) 528-3376 x 1
Customer Service and Account Information(844) 528-3376 x 2
Technical Support and Field Service(844) 528-3376 x 3
Contact Info
Q & A
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