J7328 Modifier
Niklas Terki
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If subsequent courses of treatment are given, the medical records must support the effectiveness of the prior treatment and must clearly establish reduction of patient symptomatology and medication usage. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medically necessary.
A series is defined as a set of injections for each joint and each treatment. The EJ modifier must be used with the HCPCS code for the drug administered to indicate subsequent injections of a series. The modifier is not to be used with the first injection of each series.
03/01/2019 Billing the injection procedure: Added CPT code 20611 to following statement: The appropriate site modifier (RT or LT) must be appended to CPT code 20610 or CPT code 20611 to indicate if the service was performed unilaterally and modifier (-50) must be appended to indicate if the service was performed bilaterally.
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Articles are a type of document published by the Medicare Administrative Contractors (MACs). Articles often contain coding or other guidelines and may or may not be in support of a Local Coverage Determination (LCD).
For the most part, codes are no longer included in the LCD (policy). You will find them in the Billing & Coding Articles. Try using the MCD Search to find what you're looking for. Enter the code you're looking for in the "Enter keyword, code, or document ID" box. The list of results will include documents which contain the code you entered.
Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. All other Codes (ICD-10, Bill Type, and Revenue) have moved to Articles for DME MACs, as they have for the other Local Coverage MAC types.
NCDs do not contain claims processing information like diagnosis or procedure codes nor do they give instructions to the provider on how to bill Medicare for the service or item. For this supplementary claims processing information we rely on other CMS publications, namely Change Requests (CR) Transmittals and inclusions in the Medicare Fee-For-Service Claims Processing Manual (CPM).
In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. CRs are not policy, rather CRs are used to relay instructions regarding the edits of the various claims processing systems in very descriptive, technical language usually employing the codes or code combinations likely to be encountered with claims subject to the policy in question. As clinical or administrative codes change or system or policy requirements dictate, CR instructions are updated to ensure the systems are applying the most appropriate claims processing instructions applicable to the policy.
Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it. (Or, for DME MACs only, look for an LCD.) Review the article, in particular the Coding Information section.
If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details).
2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Your information could include a keyword or topic you're interested in; a Local Coverage Determination (LCD) policy or Article ID; or a CPT/HCPCS procedure/billing code or an ICD-10-CM diagnosis code. Try entering any of this type of information provided in your denial letter.
*Note: The prescribing information for the dose and frequency of administration should be consistent with the United States (U.S.) Food and Drug Administration (FDA) approved labeling.
Use EJ modifier with the HCPCS code for the drug administered to indicate subsequent injections of a series. Do not use this modifier for the first injection of each series. A series is defined as a set of injections for each joint and each treatment.
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.
Yes. If your hospital purchased the drug through the 340B Program, you must bill the applicable modifier JG or TB for the drug to Medicare. This is specific to drugs / biologicals assigned status indicator G or K in Addendum B under the Outpatient Prospective Payment System (OPPS).
If the drug is assigned status indicator K, Medicare wants to reduce your reimbursement for the drug if it was purchased through 340B. In that scenario, it is your responsibility to bill the drug to Medicare with modifier JG. If you purchase a status indicator K drug through the 340B program, but do not bill the drug with modifier JG, you will be overpaid.
This creates a challenge for CDM coordinators, because this type of CDM maintenance is absolutely essential to compliant Medicare billing of these items. You should expect some status indicator changes quarterly. We acknowledge some hospitals manage pharmacy modifiers in a pharmacy system separate from the CDM.
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