For our bacillus Calmette-Guérin patients, our doctors will sometimes give a patient one-third dosage and treat three patients from one vial. We have been searching for proper coding, since 90586 and J9031 just say “each use,” and it is typically a one-dose vial. I have not found anything that looks appropriate for the drug. We don't want to be fraudulent so we’re seeking advice. Should we be using modifier –52 on code J9031?
You have asked a question with no good answer. During past BCG shortages, offices struggled with similar issues. For our clients, we began reporting partial doses of BCG with code J3490 (Unclassified Drugs) and used box 19 to include the drug name and National Drug Code with dosage used. The claims were often denied but were paid upon appeal based on the medical necessity to extend the drug to more patients. To date, we have not found a more accurate way to report doses split among patients.
Also from Ray Painter, MD, and Mark Painter: How to bill for catheter placement in the hospital setting
It is our understanding that some trials of partial doses were being studied, but we are not certain that these trials have resulted in supporting documentation that would allow for medical necessity support if partial dosing is provided by choice. As the reporting of partial dosing often requires appeal, make sure that you have supporting clinical or population health reasons for providing a partial dose.