BCG Billing Update 4-26-19

BCG Update

CMS has communicated with the AUA providing a few important updates.

1. A new code will be introduced on July 1, 2019. The new code; J9030 – BCG live intravesical, 1mg, will allow for more accurate reporting of the quantity of BCG administered to a patient.

2. CMS has indicated the following: “Please note that CMS has established policies to pay for claims based on the lower of the submitted charge or the amount on the ASP Drug Pricing files. For example, in the case of BCG bladder irrigation where pricing is done in increments of a full vial, if a provider administers one third of a single dose vial and does not discard the remaining amount, billing for a third of cost of the vial is consistent with policy.”

a. This would seem to indicate that CMS will accept code J0931 (current code: BCG (intravesical) per instillation) with a lower fee, consistent with payment for a one-third or one-half dose. Units may be reported to some payers using decimal format, if your practice management system and clearinghouse will clear the claim. Check with your payer to make sure that you can provide appropriate report units.

If your system does not allow reporting of reduced units it appears that Medicare will accept a reduced fee for code J3091, we recommend that you carefully calculate current allowed amounts and bill the reduce rate based on actual allowed amount until July 1, 2019 when the new code with lower unit dosing is implemented. The current allowed amount for code J3091 is $141.98, therefore a 1/3 dose has an allowed amount of $47.326 and a ½ dose has an allowed amount of $70.99.

Based on this new information PRS is recommending that you report code J9031 for BCG and not J3499 as previously recommended. Reporting of code 51720 at full value is appropriate regardless of dose.

As you may recall in our last update Novitas ruled that splitting a single dose vial was not appropriate. At this time CMS has not released its ruling to Novitas, therefore it is still considered in appropriate to split dosing among patients based on the current LCA for Novitas.

A final issue to consider is state regulations that may consider splitting a single dose vial among patients as not appropriate regardless of Medicare payment policy. For those states that will not allow splitting single dose packages a change or special exemption to the state law will be required. State licensure and other requirements for practice of medicine cannot be superseded by Medicare rulings.

We will continue to provide updates as they become available.

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Mark N. Painter is a managing Partner of PRS Consulting, LLC, the CEO of PRS, LLC and the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc. (PRS). Since co-founding PRS in 1989, Mr. Painter has served as the primary coding resource for the PRS products including Hotlines, Coding Manuals and quick reference tools, the Internet based application and seminars. He has lectured to a variety of groups concerned with health care reimbursement. Mr. Painter's extensive knowledge of physician reimbursement issues has allowed him to assist insurance companies, physicians and their staff members, legal counsel, actuaries, Specialty Societies and consultants on a daily basis. He has serves has an expert to legal counsel, bio device companies and pharmaceuticals. He was a co-chair of the Colorado Clean Claims Task Force, a committee of nationally known industry experts charged with the development of single payment edit database for the state. Mr. Painter is a CPMA. Mr. Painter received his B.A. from Grinnell College at Grinnell, Iowa.