High-Cost Injections Exceeding $99,999.99 - JE Part B

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.