States Applicable to Alert: American Samoa, Guam, Hawaii, Nevada, Northern Mariana Islands, Northern California and Southern California
Background Information: Claims processed on and after April 6, 2009, with the following Health Care Common Procedure Coding System (HCPCS) procedure codes may have been denied incorrectly if additional documentation was not submitted and the codes exceeded the MAU limit.
If these codes are billed on the same date of service as Current Procedural Teminology (CPT) codes 62368, 95990 and/or 95991 or submitted with the KD modifier, the drugs may not be compounded and administered through a pump. Therefore, additional units may be allowed.
If these drugs are 'compounded', HCPCS NOC (Not Otherwise Classified) code J3490 must be submitted. View instructions on submitting compounded drugs on the Palmetto GBA Web site.
Applies To Procedure Code(s):
J0475: Baclofen
J0735: Clonidine Hydrochloride
J1170: Dilaudid/Hydromorphone
J1230: Methadone
J2275: Morphine
J2795: Ropivacaine
J3010: Fentanyl
MAC Action:
A mass adjustment was performed on June 19, 2009.
This adjustment was for services denied with reason/remark codes 153 and N362 for claims processed on and after April 6, 2009, through May 27, 2009.
There was a total of 53 claims adjusted for American Samoa, Guam, Hawaii, Nevada and Northern Mariana Islands; 170 claims adjusted for Northern California; and 191 claims adjusted for Southern California.
Remark /Reason Codes:
153 - Payer deems the information submitted does not support this dosage.
N362 - The number of days or Units of Service exceeds the acceptable maximum.
Provider Action: None required.
Date Reported: May 13, 2009
Date Resolved: June 19, 2009