Blue Cross and Avastin injections

Edit: Final status update at the bottom of the article 10/07/15

I am always telling my doctors and employees that in our profession the rules change around here every 10 minutes. We have spent the last two weeks finding out again how true that is. One of the providers we bill for is an ophthalmologist and he does a lot of Avastin injections. Blue Cross has recently started denying the CPT code J9035. They still pay the 67028, but they are stating that the code J9035 is not indicated for ophthalmological services.

And, I have to say, they kind of have a point.

The CPT book description of J9035 says Injection, bevacizumab, 10 mg. That means is code is for the full 10 mg of meds, not up to 10 mg. For macular degeneration (362.52) and diabetes with ophthalmic manifestations (250.52, 362.07) the typical injection is 1.25 mg.

We’ve been in contact with the American Academy of Ophthalmic Executives and they said that Blue Cross will not be accepting the J9035 from ophthalmologists any longer and that we have a few options.

1. Use the code C9257 which is injection, Bevacizumab, 0.25 mg and use 5 units of that.

2. Use the code J3590 which is just the unclassified biologics code, and then put the NDC in box 19. I know that most of you have practice management systems which puts the NDC number in the correct 5010 loop, but we were told that we also have to put that information in box 19.

3.  Use the RT/LT modifiers on both the 67028 and J9035 with the NDC number in box 19. This suggestion was made on the AAOE message boards by another biller and I have not been able to verify whether or not this will work.

The issue with the first two suggestions is that the reimbursement amount is going to be significantly less than we are used to getting and the issue with the third suggestion is that it may not work. Personally, I am going to try the J3590 code with the NDC in box 19 and see what happens. I’ll keep you guys updated.

Edit 08/24/15: Hello everyone. We are still fighting this with Blue Cross. What I ended up doing was submitting one service with the new J3590 code and one service with the J9035 RT. Both of those were pended requesting a detailed treatment plan. I finally managed to drag out of Blue Cross what THEY want in terms of a treatment plan. And here it is

1. Clinical indication
2. A stated goal for the patient in terms of his condition
3. They want to know if the treatment plan is having the desired affect
4. They also said that if we have attempted any alternative treatments, we should indicate if we are going to be utilizing those concurrently or if we are discontinuing those
They didn’t say this specifically, but I got the impression that they want to know when the patient will be all better and they will get to stop paying for this kind of thing. I told the woman I spoke with, that for patients with macular degeneration “getting better” isn’t really a thing. The point of the injections is to preserve what eyesight the patient still has. She said “then that’s what you probably want to say in your plan.”

If any of you are having trouble getting the Avastin paid by Blue Cross try sending in something like this with the office notes. I’ll continue to update you as I get more information.

Edit 10/07/15: Finally! We just got the answers on our test claims back. The charge with the J9035 – RT was denied. The charge for the J3590 was paid, albeit at an allowed amount of $47.50. Blue Cross used to pay about $60.00 for the J9035, so we are taking a bit of a cut. We are sending all our outstanding Avastin claims to Blue Cross with the J3590. Please remember to put the NDC number in the proper box when you use that code though. Please be aware, Medicare also has some new guidelines for the Avastin starting 10/01/15. Anyone having issues with the Avastin injections for Blue Cross, go ahead and email or call.



Filed under blue cross, Denials, Medical Billing, ophthalmology

3 responses to “Blue Cross and Avastin injections

  1. Hi from Colorado; We are having the same issue with the Blues and Avastin. We followed the J3590 billing scenario and submitted records; billing that code with 1 unit and the NDC code originally allowed the full billed amount as an allowance. This week, we are receiving an avalanche of refund requests from the Blues stating that $1.41 is the correct allowance. We asked the claims department to review the allowance; they determined $1.41 is the correct allowance and we will have to pay the $ back.
    My question is, with the J3590 what NCD code did you bill and how many units did you bill?

    • For us, Blue Cross allowed half of the billed amount. Our standard price for the J9035 was $95.00, so I used that as well when I changed everything to J3590. Blue Cross allowed $47.50 for each line item and we billed one unit. I haven’t received any refund requests yet, but I will keep you updated. Also, Blue Cross is AT LEAST required to reimburse you for the cost of the medication even if you aren’t making any money on it. You can try appealing with a copy of your invoice. Also, there are far more expensive medications that Blue Cross pays without giving us this kind of crap. But the up-front investment is somewhat prohibitive. In my appeal letter I did mention that if they continue to give us issues with paying the Avastin, the doctor will have no choice but to use alternate treatments that will cost Blue Cross $1200.00 per injection. Thank you so much for the feedback!

    • I also missed your question about the NDC number. We used 05024206001 and in the description I marked “AVASTIN 1.25 MG”. When I set the code up in my system I set it as Quantity “1” and Unit of Measure “Units”.

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