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.
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.
posted by MADHU at
September 20, 2010
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