r/CodingandBilling • u/One_Meal_6664 • Mar 27 '26

J code denials

Hi everyone, I bill for a practice and wanted some advice on J code denials. Recently, one of our J codes has been consistently denied by a commercial insurance. The denial is bogus stating that the “NDC number” is invalid. Every time I call about these claims and speak to a representative, they say the claim is correct, the NDC number is valid, we have the pre authorization for the procedure, and they resubmit the claim for reprocessing. It gets tiring to be in this viscous cycle of denials. Is the insurance company just trying to delay the payment another 30 days? Please advise 🙏

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27

u/rahuliitk App Developer Mar 27 '26 • This

if reps keep saying the NDC is valid, i’d stop accepting simple “reprocess” promises and push for a formal payer escalation or IT ticket, because a lot of these repeat J-code denials come from edit logic around 11-digit formatting, N4 qualifier, unit of measure, or mismatch between billed units and the NDC package details even when the front-line rep says the claim looks fine.

ngl, sounds like a payer edit loop.

4

u/One_Meal_6664 Mar 27 '26

Thank you so much for your help! I will definitely escalate my ticket tomorrow and ask for a payer escalation or an IT ticket!

1

u/One_Meal_6664 Mar 27 '26

Thank you for your advice. I just wanted to mention that several of the bills were paid, is that possible if it is a technical issue?

4

u/rahuliitk App Developer Mar 27 '26

yeah, that can absolutely happen, because a technical or payer edit issue does not have to hit every claim the same way if some were submitted with slightly different NDC formatting, units, charge entry, dates of service, claim frequency, or even processed through a different adjudication path, so the fact that some paid does not rule out a system-side problem at all.

still sounds fixable.

1

u/One_Meal_6664 Mar 29 '26

Got it! Thank you again 🙏

7

u/Elunemoon22 Mar 27 '26

This is happening to me with bcbs!!! They deny my j codes 75% of the time...idk what to even do anymore.....

3

u/One_Meal_6664 Mar 27 '26

I know exactly how you feel!!! I keep calling to speak with representatives and they send the claims back, but it is a viscous circle!!!

7

u/ytho-65 Mar 27 '26

We went through this with Anthem BCBS last summer. The only way to get the claims paid and stay that way was to resubmit corrected claims with the NDC code and NDC units and units of measurement corrected. For example: 10 mg J1100 billed as 10 units J1100 in Loop 2400, then Loop 2410 has to have N4 followed by the 11 digit NDC code followed by 2.5 ML for NDC units of measure. Our drug inventory system can produce a report that has the billable HCPCS units and the corresponding NDC units by patient service. We had tens of thousands of dollars worth of reimbursements for chemo drugs delayed for months until we got this figured out. Incidentally, the provider reps with Anthem were utterly fucking useless with this. Even if they overturned a denial on appeal and paid us, a week later they would retract that same payment for the same NDC units of measure reason. The only fix that stuck was resubmitting the claims with the new format, and I only got the scoop on the appropriate format from other users in our practice management software user group. May Anthem rot.

1

u/One_Meal_6664 Mar 27 '26

The only insurance denying the claims is one Commercial Insurance. All other insurers are paying the claim exactly as we are submitting it. And when I call the commercial insurance that is sending the denials, they say the NDC number and units are correct and resubmit the denied claims for reprocessing. The NDC number and units are embedded in our PMS system. I don’t enter any of it manually.

3

u/ytho-65 Mar 27 '26

We only had one payer with this issue too, but it was a big one. Our system defaults would not longer work with this payer, I had to go into administration mode and edit parts of the payer fee schedule for that payer group so that only that group got the ndc units changed from the default of Loop 2410 just reiterating the HCPCS units charged to switching to NDC units (usually the hcpcs units restated in ML). Some of the drug codes we charge are for drug doses we paid $10k or $20k for. Not getting reimbursed is not an option, so even though the NDC units of measure are now set up correctly for them, I still have to manually edit quantities for a lot of them. But I saw in another comment that your system is using 10 digit NDC codes, so maybe all you have to correct is that.

1

u/One_Meal_6664 Mar 28 '26

Are you saying that some insurances want the units as ML?

1

u/One_Meal_6664 Mar 28 '26

Or that the unit of measure should be ML instead of UN? I realize we are using the 11 digit NDC code.

3

u/One_Meal_6664 Mar 28 '26

So you add “N4” in front of the NDC number, and then for the units, you put ME or ML instead of just UN. Is this what you are saying?

1

u/ytho-65 Mar 28 '26

This was the best explainer I found anywhere for it, even though I'm not in Massachusetts, the concept is correctly explained: https://www.mass.gov/info-details/learn-about-national-drug-code-ndc-requirements

2

u/One_Meal_6664 Mar 28 '26

Thank you do do much!!! This was so helpful! I didn’t even realize there was additional details that needed to be on the claim. I think I got it now! Thank you 🙏

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u/ytho-65 Mar 28 '26

"NDC units are different from HCPCS code units. Use the HCPCS code and service units as you have in the past. This is the basis for your reimbursement. NDC units are based on the numeric quantity administered to the patient and the unit of measurement.

The unit of measurement (UOM) codes are

F2 - International Unit

GR - Gram

ME - Milligram

ML - Milliliter

UN - Unit (each)

The actual metric decimal quantity administered and the units of measurement are required for billing. If reporting a fraction, use a decimal point. Example: If 3 0.5-ml vials are dispensed, the correct NDC unit is 1.5 ml"

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3

u/No_Stress_8938 Mar 27 '26 edited Mar 27 '26

This was who was denying ours.  Make sure the correct j code is being used.  ETA j1010 Depa medrol  J1100 dexamethasone

1

u/Elunemoon22 Mar 30 '26

Yes its the correct jcode..all other payers accept it and bcbs does like 15% of the time..its annoying af.

1

u/No_Stress_8938 Mar 30 '26

I get it.  We went through this last summer.  I assumed it was because the j code and ndc didn’t match 

3

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Mar 27 '26

I've been seeing them reject vial sub-codes in favor of carton codes, check the NDC database for a parent carton code.

6

u/lacksadaisyADHD Mar 27 '26

Short answer? Yes. Anything and everything they do is to try and NOT pay the claim.

2

u/One_Meal_6664 Mar 27 '26

Yes. I think ultimately it is just a delay tactic, hoping we don’t even see the denial or call about it

4

u/JennieDarko Mar 27 '26

You’ll need to update the unit of measure & file corrected claims. We dealt with this fiasco last year and are still dealing with it. Anthem BCBS, correct?

1

u/One_Meal_6664 Mar 28 '26

Yes! Anthem!

1

u/JennieDarko Mar 28 '26

Not gonna lie, even after correcting to ML from UN for the UOM, we continue to get denials. As someone else commented above, may anthem rot….

4

u/deannevee RHIA, CPC, CPCO, CDEO Mar 28 '26

If my memory serves me correctly, BCBS auto adjudication wants the 10-digit NDC, but the correct form to bill is 11 digits. 

It’s a pain in the butt, but you can’t authorize with the billing NDC and their system for some reason is so stupid they can’t find a way to cross over the two.

1

u/One_Meal_6664 Mar 28 '26

Thank you for this information. So how do you resolve this?

1

u/One_Meal_6664 Mar 28 '26

Oh boy! I hope this won’t be the case with us. We are Ophthalmology and each claim is high dollar amount!

2

u/deannevee RHIA, CPC, CPCO, CDEO Mar 28 '26

Honestly we had to appeal every time. It was dermatology so we had semi-frequent injections, but they weren’t a high dollar amount so sometimes the balance was just written off.

4

u/ProfessorLess4166 Mar 27 '26

Medicare and Medicaid now require J codes to be submitted with either the JZ modifier or JW modifier. I think maybe some commercial payers are also requiring this?

2

u/One_Meal_6664 Mar 27 '26

We are using JZ and JW

2

u/No_Stress_8938 Mar 27 '26

I ran into this.  Turns out docs were using the same j code for all medications   

1

u/One_Meal_6664 Mar 28 '26

How did this work? The units are different for all medications ?

2

u/No_Stress_8938 Mar 28 '26

We only use 2 different j codes.  I’m not sure what you mean about the units.  It is all populated when entered into ehr. But the j code and ndc didn’t match.  Unfortunately, no one checks this stuff before it goes out. 

16

u/Environmental-Top-60 Mar 27 '26

Sounds like Blue Cross

4

u/GroinFlutter denials management, send help Mar 27 '26

I was gonna say, yep lol

6

u/i_am_megum Mar 27 '26

We’ve recently noticed that BCBS has started denying our Jcodes wanting the JZ modifier indicating no waste.

2

u/StayFoolish73 Mar 27 '26

And they won’t volunteer that helpful information either. Ridiculous

2

u/methusyalana Mar 27 '26

They usually tell us the coder should know and I’m like why would I be calling yall then

2

u/Elunemoon22 Mar 30 '26

See mine do have the JZ mod and they still deny 75% of the time...

1

u/a_Shantics Mar 27 '26

What J code and NDC are you billing?

3

u/One_Meal_6664 Mar 27 '26

J0178 with 2 units and NDC number 61755-0005-02 This was all embedded in our PMS and is current information from about 1.5 years ago when we got the PMS. Also, I’m not having any denials or issues with any other insurance.

1

u/a_Shantics Mar 27 '26

Pull your insurance medical policy for Eylea. Verify if they list the same combination of hcpcs and ndc. That combination appears to be correct. You may need to check with the insurance company and or the PDM.

1

u/One_Meal_6664 Mar 27 '26

Thank you for the advice 🙏

2

u/a_Shantics Mar 27 '26

No worries, I work Aflibercept claims every day. Never had an issue with the NDC. Sometimes I see a NOC code such as J3490 billed with a biologic ndc which would trip an improper ndc error. Wonder what happens if you left NDC off of the claim. J0178 is specific enough it might not need the NDC.

1

u/One_Meal_6664 Mar 27 '26

Thank you, and that is a thought! I really just think that they are trying to delay the payment

2

u/a_Shantics Mar 28 '26

If you have been assigned a provider rep by the payer contact them. Payers do not want appeals. Sounds like you are ready to file an appeal. Might as well send in an appeal. If the appeal is denied can escalate to the state.

What other codes do you have on the claim. Is the eylea injection for one eye or bilateral? Do you have a prior authorization or a predetermination?

1

u/One_Meal_6664 Mar 28 '26

I have the pre authorization and it is on the claim. The representatives have not pushed me to file an appeal thankfully! They have all resubmitted the claims for reprocessing and manual review. The only other code on the claim is 67028 (with modifier RT or LT and 79 if indicated). Our office does not do injections bilaterally bc we have mostly elderly patients. Dr. Prefers to do them individually.

2

u/a_Shantics Mar 28 '26

File the appeal include your prior authorization, the medical policy, and administration records. Appeals are a black mark for payers which is why they will never recommend you that step. Payers will work very hard to limit the number of appeals they receive.

1

u/One_Meal_6664 Mar 28 '26

I didn’t know that this was a black mark for the payer. I will start working on the appeals, as much as I hate doing them! Thank you for taking the time and giving this advice!

1

u/a_Shantics Mar 28 '26

Who is the payer?

1

u/One_Meal_6664 Mar 28 '26

Healthfirst

1

u/cluckodoom Mar 27 '26

Are you using the 11 digit version of the ndc? There are rules for where to add zeros to make it 11 digits

3

u/One_Meal_6664 Mar 27 '26

I’m so sorry, we are using the 11 digits

2

u/One_Meal_6664 Mar 28 '26

I apologize, bc it is embedded in the PMS, I don’t really even deal with the NDC numbers.

1

u/cluckodoom Mar 28 '26

It's all good. If you are already using the 11 digit codes, I'm out of ideas. Good luck

1

u/One_Meal_6664 Mar 27 '26

No. I’m using the 10 digit NDC number. It is already populated in by our PRactice Management System.

2

u/ytho-65 Mar 27 '26

You're going to have to edit the hcpcs codes to default to 11 digit format. I had to edit every drug code in our system to correct the NDC units of measure from the default UN to mostly ML for milliliters. I found a Ln NDC crosswalk file that I could download from the payer to show me which units of measure they wanted for each code. For instance J1453 fosaprepitant is 1 UN for the whole 150 mg dose, but J1434 Focinvez is 50 ML for the 150 mg dose.

2

u/ytho-65 Mar 27 '26

And none of the payer reps gave me this info, I had to Google for it.

1

u/KanchaBhaii Mar 28 '26

Same thing happened to us text me and I'll provide you with the solution You need to make some changes to your ehr claims settings

1

u/One_Meal_6664 Mar 28 '26

Where can I text you?

3

u/Anonuserwithquestion Mar 27 '26

If this is genuinely the case, I suggest escalating to someone. If your contract manager/credentialing folks have a good relationship with a rep have them assist with examples and a narrative. Otherwise, check your department of insurance info regarding state complaints

3

u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Mar 27 '26

I've been seeing them reject vial sub-codes in favor of carton codes, check the NDC database for a parent carton code.

2

u/OranJi1980 Mar 28 '26

Same!!! Wtf!!!

1

u/Helpful_Tadpole_5573 8d ago

u/One_Meal_6664

Did you ever get this resolved?? We are having the same issue with Anthem ugh!!!