Billing for CAP Drugs

The Approved CAP Vendor submits CAP drug claims to the CAP Designated Carrier and collects applicable deductible and coinsurance from the beneficiary.
Participating CAP Physicians submit CAP drug administration claims to their local carrier, and these claims must include a “no pay” line that contains information on the administered CAP drug.

The J1 Modifier
This modifier is used in the drug administration claim on a “no pay” line and indicates that the drug was obtained through CAP. A dose-specific prescription order number is also included on the “no pay” line.
The prescription order number will be supplied by the Approved CAP Vendor. It may be combined on the same line with a J2 modifier.

J2 – “Emergency Restocking” modifier
This modifier is used to restock drugs used in an emergency . These claims should include the:
• Approved CAP Vendor’s provided prescription order number
• HCPCS code(s) for CAP drug with the “J1” no-pay modifier and the “J2” modifier on that same line
• HCPCS code(s) that include the administration of each CAP drug on separate lines

The local carrier may conduct a post payment review to assess the appropriate use of this provision. For more information on the ‘Emergency Restocking’ provision, please refer to the criteria in the section “Ordering CAP Drugs.”

J3 – “Furnish As Written” Modifier
This modifier is used when drug as written is not available through the CAP. Use J3 for “furnish as written” drugs to be paid outside the CAP program via the average sales price (ASP) methodology. The J3 modifier should not be added to a claim line with a J1 or J2 modifier.
For more information on the ‘Furnish As Written’ provision, please refer to the section “Ordering CAP Drugs.”

M2 – “Medicare Secondary Payer” Modifier
The M2 modifier is used when:
• Another insurance is primary to Medicare and the CAP physician orders drug via an alternate method, -OR-
• The CAP physician’s office later determines that Medicare is primary and that the drug should have been ordered through the Approved CAP Vendor.

CAP Physician Election Guide

The Medicare Part B Drug Competitive Acquisition Program (CAP) is an alternative to the Average Sales Price (ASP) method of acquiring many Part B drugs and biological administered incident to a physician’s services. CAP participation is open to Medicare physicians who administer drugs under the "incident to" provision in their offices.

Ordering CAP Drugs

Participating CAP Physicians must obtain all drugs on the CAP drug list from their chosen Approved CAP Vendor. If a Participating CAP Physician elects to obtain drugs through the CAP, the physician will complete an order form and fax it to the Approved CAP Vendor prior to the date of administration. Physicians must order drug on a patient- Specific basis. A Participating CAP Physician cannot use the CAP to supply a general stock of medication that would be used for a multiple number of patients except for emergency restocking as described below.

Emergency Restocking
For emergency situations, a Participating CAP Physician may administer drugs from the office inventory when all of the following conditions are met:
• The drugs are required immediately,

• The physician could not have anticipated the need for the drugs,

• The vendor could not have delivered the drugs in a timely manner, and

• The drugs were administered in an emergency situation.

If all of these conditions are met, drugs acquired through the CAP may replace the medication from the physician’s private inventory.

MODIFIER 79

DEFINATION : UNRELATED PROCEDURE BY THE SAME PHYSICIAN DURING THE POST OPERATIVE PERIOD.

USAGE:

THE TWO PROCEDURE ARE PERFORMED BY THE SAME DOCTOR.

TO DESCRIBE AN UNRELATED PROCEDURE PERFORMED DURING THE POST OPERATIVE PERIOD OF THE ORIGINAL PROCEDURE.

INAPPROPRIATE USAGE :

THE PROCEDURE PERFORMED IS RELATED TO THE ORIGINAL PROCEDURE OR A STAGED PROCEDURE

MODIFIER ORDER

The positioning of modifiers following the procedure codes aids in correctly processing services.For example, modifier -80 is necessary to identify a service as an assistant surgeon, and should be used in the first position. Other modifiers are exception modifiers, and tell the system to overlook the rule in this case, such as in NCCI editing.
The modifiers should be in the first or second position whenever possible
• E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, GN, GO, GP, LC, LD, LR, LT, QA, QR,QV, Q3, RC, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 22, 24, 25, 50, 55, 59, 76, 80, 81, 90,91, 99

• These modifiers must remain on the detail line in the remaining fields
AK, GA, GB, Q4,`

Global Surgical Split Billing

If different physicians perform portions of the global service, modifiers should be used with the surgical procedure code having a 90 day postoperative period to indicate what portion of the service each provided. Each physician will be reimbursed a percentage of the global fee. The percentages allocated for pre-operative,intra-operative and post-operative services will vary foreach surgical procedure. The sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services.

-54 Surgical Care Only: When one physician performs a surgical procedure and another
provides postoperative management, surgical services may be identified by adding
modifier -54 to the usual procedure number.

-55 Postoperative Management Only: When one physician performed the postoperative
management and another physician performed the surgical procedure, the postoperative
component may be identified by adding modifier -55 to the usual procedure number.

-56 Preoperative Management Only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperativecomponent may be identified by adding the modifier -56 to the usual procedure number.

This modifier is not valid for Medicare claims.