High-Cost Injections Exceeding $99,999.99

The CMS claims processing system has a limit for the total dollar amount submitted per claim. The total digits that can be accepted on a claim is seven. When claim amounts exceed seven digits, the claim must be split into two when billing for dollar amounts above $99,999.99.

First claim:

  • Include drug code billed or unlisted code (i.e., J3490)
  • In the comment field, enter ‘claim 1 of 2’
  • Units indicate appropriate number for the dollar billed on the first claim when billing with a J-code assigned for the drug
    • Billing the unlisted code, units are 1 (one) with correct dosage amount indicated in Item 19 comments field
  • Appropriate administration code could be on the first or second claim; not on both

Second claim:

  • Include same drug code billed on the first claim, and append modifier 76 to indicate repeat service
  • In the comment field, enter ‘claim 2 of 2’
  • Units indicate appropriate number for the dollar billed on the second claim when billing with a J-code assigned for the drug
    • Billing the unlisted code, units are 1 (one) with correct dosage amount indicated in Item 19 comments field

Example: When billing an injection for full 25 mg allowed every 3 months per FDA guidelines:

  • First claim units could be 13 mg with the appropriate dosage dollar amount
  • Second claim units could be 12 mg with the remaining dosage dollar amount

Possible Denial reasons

  • Billing unlisted J-code when the injection has an assigned J-code
  • Missing information in the Item 19 comments field
    • drug name, dosage, claim 1 of 2, or 2 of 2
  • Modifier 76 was not included on subsequent claim

Note: Weight-Based Dosing in High-Cost Drugs: For efficient claims processing, Noridian encourages providers to include the patient's weight in kg in 2400 NTE Segment Loop for electronic claims, or Box 19 for paper claims.

 

Last Updated Aug 04 , 2023