HCPCS Modifiers Right and Get the Reimbursements You Deserve

Modifiers are certainly important for reimbursement and compliance; if you use them correctly, you can have a positive impact on your reimbursement. Modifiers are two digit codes that modify a service or procedure under certain circumstances. These modifiers may add information or change the description and give more specificity to the service or procedure provided. Append the right modifier and see how your reimbursement heads for the better.

Modifier assignments can be quite intriguing to coders. When trying to understand if a modifier is correct, ask if the following apply:

Was the same service carried out more than once on the same day?

Will a modifier do away the appearance of duplicate billing?

Will the modifier add more information on the anatomic site of the procedure?

If these circumstances apply, then it may be just right to go ahead and append a modifier to the procedure code. Also see to it that the documentation in the medical record supports the use of the modifier.

The modifiers are divided into two levels:

Level I

Level II

The Level II modifiers are called HCPCS modifiers and are annually updated. These HCPCS modifiers are alphanumeric or two letters. Sometimes insurers ask suppliers that a HCPCS code must be accompanied by code modifier to provide added information regarding the service identified by the HCPCS code.

Normally, HCPCS Level II modifiers are required to add specificity to the reporting of procedures carried out on eyelids, fingers, coronary arteries and toes.

Using the HCPCS modifiers the right way will certainly see your reimbursements look up.

HCPCS: Q2048, Q2049 Will Stir Your Liposomal Doxorubicin HCL Coding This Summer

CMS would no longer be using J9001 for Doxil once the change happens in July.

One of the side effects of drug shortages is that coders have to determine which HCPCS codes to use for replacement drugs. While deciding how to report two substitution drugs accurately -- Lipodox and Fusilev – you must consider these recent updates from CMS and Noridian Medicare.

Prepare to Use Q2049 This Summer

A shortage of Doxil has led to the temporary importation of a replacement drug, Lipodox. Both Doxil and Lipodox include a doxorubicin hydrochloride liposome injection.

CMS has declared new HCPCS codes for Lipodox and Doxil. The codes will become effective July 1, 2012.

As you can understand from the new codes’ definitions, they differentiate between Doxil and Lipodox:

• Q2048 (Injection, doxorubicin hydrochloride, liposomal, Doxil, 10 mg)
• Q2049 (Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg)

To make way for these new HCPCS codes, the July HCPCS update specifies it will revise Doxil’s current code J9001 (Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg) and modify its coverage status to "I." That status means the code is not payable by Medicare (as of July 1).

HCPCS Codes Q2048 and Q2049 both show coverage status "C," demonstrating coverage is at the carrier’s discretion.

Prior to the announcement of the new codes, at least one payer, Noridian Medicare, had instructed its providers to report J9001 for imported Lipodox.

In the payer’s words: Doxil® (J9001) may be replaced with Lipodox® (J9001) which temporarily must be coded as J9001 -- until further notice," as per the March 20, 2012, announcement.

Uses: Physicians may order liposomal doxorubicin HCL to treat ovarian cancer when platinum-based chemotherapy has failed or to treat AIDS-related Kaposi’s sarcoma when chemotherapy has failed. An additional indication is combination with bortezomib (Velcade) to treat multiple myeloma when the patient has received prior therapy other than bortezomib.

Swap J0640 for J0641 for Leucovorin Replacement

Another drug shortage oncology coders have had to face involves leucovorin. The HCPCS codes and agents involved are as follows:

• Leucovorin: J0640 (Injection, leucovorin calcium, per 50 mg)
• Levoleucovorin (Fusilev): J0641 (Injection, levoleucovorin calcium, 0.5 mg)

Noridian spoke of this issue in the same March 20 announcement that discussed Lipodox. The contractor instructed its providers that "Leucovorin (J0640) may be substituted with levoleucovorin (J0641) until such time as the shortage is fixed.

Uses: Before you report either leucovorin or levoleucovorin, ensure that the documentation supports medical necessity. Leucovorin is only required in limited circumstances where folinic acid is required and the patient cannot use regular folate/folic acid. The physician may order it to counteract definite effects of methotrexate or enhance certain effects of 5-fluorouracil.