Procedure for Claim Submission with J-codes

The CMS has developed the Healthcare Common Procedure Coding System (HCPCS) for reporting medical procedures and services. Some of the most commonly used HCPCS Level II Codes, J-codes are used for non-orally administered medication, chemotherapy, and immunosuppressive drugs, and inhalation solutions as well as some orally administered drugs.

Submitting Claims with J-codes:

HIPAA required that all medical providers use standardized coding systems when submitting their claims for services and supplies. J-codes are a part of that system and include drugs that ordinarily cannot be self-administered. In addition, they must meet all the general requirements for coverage of items as the incident to a physician’s services. Generally, prescription and non-prescription drugs and biologicals purchased by or dispensed to a patient are not covered.

It is important that claims are submitted with the most accurate information when billing for injectable medications that are administered in the office during a patient’s visit. These Level II codes are five characters in length and are comprised of one letter and four numbers. The code for a drug will include the J-code, the Name of the drug (usually is generic, but can be product-specific), and a dosage. However, drugs dispensed to a patient and immunizations are likely not covered by a J code. The use of a J code may be accompanied by a physician’s procedure-based CPT code. When billing for trigger point injections, make sure to use this J code to report the trigger point drug injected.

Here is an example. A patient receives an injection of 20 mg of adalimumab to temporarily relieve the signs of rheumatoid arthritis. If you received this medical report, leaving aside the CPT procedure code and the ICD diagnosis code, you’d look at the amount of medication and the type of medication. You’d also know, from going over the HCPCS Level II format, that you’re looking at a J-code—a drug administered any way except orally. Therefore, you would look up adalimumab and find the J-code J0135, “injection, adalimumab, 20 mg.” That’s your HCPCS Level II code, and that’s what you’d put in if you were creating a claim for Medicare, Medicaid, or one of the many other payers that take HCPCS codes.

Take another example, J0456 reads “Injection, azithromycin, 500mg/Use this code for Zithromax”. A patient that received up to 500 mg of Zithromax would be billed for J0456 with units of 1. The codes are found in the HCPCS Manual in the “J Codes Drugs J0120-J8499″ section.

AAPC certified medical coding specialists at Medical Billers and Coders (MBC) is experienced in assigning even the complex code sets for diverse specialties including pain management, orthopedic, and radiology.

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