Pharmacy Question for the Week of April 9, 2018

Question:

We get a local coverage determination (LCD) edit for J1815 (injection, insulin, per 5 units) for many accounts. Many times, coders have coded DM with complications (without coma), but we couldn’t result the LCD edit for J1815. Do you have any suggestions about LCD edits for J1815 issue with diagnosis issue?

Answer:

Novitas wants providers to make a determination whether the insulin would be considered self-administered or not. It is recommended that your organization review the Novitas Article A53127 against the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 50.2 for billing guidance. On the surface, Novitas considers the administration of insulin self-administered based on “usually.” This means if the drug is self-administered by more than 50 percent of the Medicare beneficiaries, it is excluded from coverage. Because insulin may need to be administered in an urgent/emergent situation, then the patient diagnosis must reflect one of these conditions in order to bill Medicare for the drug. This would meet the exception for “acute condition” based on the MBPM, section 50.2D. When an exception is not met, then the drug is considered self-administered, and the hospital will need to follow its internal policies for either billing this drug with a revenue code 637 in the non-covered column on the claim or make patient financially responsible.