Recent experiences with Varithena claims have produced results we felt would be interesting to the venous community, so we thought we would share. As noted in a previous article by AJ Riviezzo, the claims have paid with some inconsistencies. We have since submitted a larger sample of claims and here are our findings.
There have been some challenges with authorizations. Some payers are authorizing consistently, while others are denying outright. The denials state Experimental and Investigational, which is to be expected with a newer treatment, others are citing that 37799 is inappropriate and that CPT codes 36470 or 36471 should be used. Some state the services are not medically necessary. Regardless of the response, an authorization is typically required prior to treatment. So if a denial is received, an appeal would be indicated or a new course of action needs to be followed.
Authorized claims for CPT 37799 are processing with rates that are, for the most part, fair to good. Average payments come in at or around 1000-1500. This is on par with the cross walked code of 36475 or 36478. All payers are requesting medical records to complete processing and our recommendation is to send these with a paper copy of the electronic claim shortly after filing for the quickest response. Make sure to review these records for completeness! Claims are scrutinized closely for medical necessity and incomplete records will cause delays.
Claims for HCPCS J3490 are not paying with as much reliability as the procedure code 37799.
Some of the issues we have noted are denials stating that the drug in inclusive to the procedure. Medicare contractors WPS and NGS have both denied for this reason. We have also seen underpayments of this code, anywhere from .07 cents on up. It has been all over the board here, with no real rhyme or reason. One identifiable issue has been language in the contract with the payer stating payment will be a percentage of the billed charge for unlisted drugs.
Reviewing your contract language can be helpful. Pricing for the J code appropriately is recommended and we are sending claims out at 150% – 200% of invoice for the Varithena.
Be sure your claim notes for each line item are clear, concise, and fit entirely within the character space allowed. Include in the note an exact description of the procedure, and what it can be compared to. An example would be, “37799 Varithena Chemical Ablation of GSV comparable to 36475.” Be sure the drug note includes the drug name, strength, dose, and NDC#. Your notes should be located in box 19 of a paper claim, on the line item notes area of a 02/12 form, or in loop 2300 or 2400 of the 5010 e-claim format. Check with your software vendor if you are unsure about these fields.
While submitting for any new technology can be a challenge, and the results are never guaranteed, it is not something that is impossible to do. A good course of action is to start with a trial. Select a limited number of patients with your top contracted insurance companies and submit your claims. See what response you get and get a feel for what each payer requires from your practice to be reimbursed appropriately. Each payer can be a little different, so don’t expect that what works for one will work for another.
Closely tracking these responses will give you a real feel for how these services will fit into your practice.
We are having a hard time getting Medicare to pay for these injections. I am confused as to how to bill the medication. The invoice shows Varithenia 18 ML/INJ and the price is $3,195.00 Then there is Varithenia Multi-admin pk they each have a separate NDC # Are both billed? What description should be on the 37799?
What description is used for the J3490?
Varithenia is not a covered medication under Medicare Part B. This must bill through the Part D benefits and a Prior Auth will most likely need to be obtained to show medical necessity.
I hope this helps.
The Jcode 3490 is a miscellaneous code, the medication itself does not have its own Jcode at this time. That is why there is some trouble with payment. It is very important to get the Prior Authorization.