Compound Drugs Administered for Pain Management May Be Rejected if Not Submitted Correctly


When billing for the use of compounded medications, use the appropriate HCPCS code (see below) on a single claim line, quantity billed = 1 and enter the name and total dose (in mg or mcg) of each drug of the refill in the appropriate comment loop of electronic claims or Box 19 of the CMS 1500. Version 5010 requires Loop 2400 SV101-7 to be completed for Not Otherwise Classified (NOC) codes. If further information is required, Loop 2400 NTE,02 may be utilized in addition to SV101-7. If box 19, of the paper claim, cannot accommodate all the information, attach the information to the paper claim. An invoice is not required. 

HCPCS code J7999 — for dates of service on and after January 1, 2016.

Evaluation and management codes, pump refilling codes and pump adjustment codes are also reimbursable if clinically appropriate during the visit.

Services are rejected if the criterion listed above is not met when billing for compounded medications. Rejected services must be submitted as new claims, and are not eligible for appeal or reopening.

In order to avoid resubmissions and appeals and receive the highest payment possible for the compound drugs, please ensure that the total dosage for each drug is indicated and included with the claim.

Example

  • 140 mcg/20 ml Baclofen is administered
    • Submit 2,800 mcg as the total dosage
  • 9 mcg/20 ml Prialt is administered
    • Submit 180 mcg as the total dosage





Last Updated: 12/11/2020