Beginning July 1, 2020, Indiana Medicaid, including both fee-for-service and managed care plans, will begin reimbursing Emergency Medical Services (EMS) provider agencies for administering naloxone. Below, we’ve provided guidelines for documenting, coding and billing this newly reimbursed service.

Documentation Requirements

To ensure proper documentation of the patient encounter when administering naloxone, EMS providers should include the following information in the patient case record:

• Whether transportation was provided and, if so, the destination; 
• The 10- or 11-digit National Drug Code (NDC) of the drug taken from the packaging (including hyphens and spaces); 
• The amount of drug administered.

Use these guidelines for documenting naloxone amounts:

• Each administered dose of the prefilled nasal spray is considered one unit. Record the total number of units administered.
• When the liquid (vial) form of naloxone is administered (regardless of the method of administration, such as injection, intravenous, or atomizer), record the total milligrams of naloxone and the total milliliters of fluid of each individual dose administered.
• If the EMS provider administers both the prefilled nasal spray and the liquid naloxone, both the NDC and total amounts should be recorded separately.

Billing Requirements

Under the new guidelines, Indiana Health Coverage Programs (IHCP) will reimburse EMS transportation providers (provider specialty 260 – Ambulance) for naloxone, its administration, and any resulting transportation as nonbrokered services. If transportation occurs, both the drug and its administration must be billed together on the same claim to receive reimbursement. (If transportation is not provided, see the instructions below.) The administration fee can be billed only once per drug form.

To bill for the drug and the administration, use the following codes and units by form: 

• Prefilled nasal spray 
  • DRUG CODE: J3490
  • UNITS:  One dose of the nasal form equals one unit. Providers may bill multiple doses of prefilled nasal spray on one line of the claim using NDC quantity units. For example, if the EMS provider administered 3 units of the prefilled nasal spray, the provider bills 1 unit of procedure code J3490 with an NDC quantity of 3 units.
  • ADMINISTRATION CODE: 96372 with Modifier U1 (indicating nasal administration)
• Liquid vial 
  • DRUG CODE: J2310
  • UNITS: Units for the liquid (vial) form are measured in milligrams (mg). Enter the total number of milligrams, rounded up to the nearest whole number, as the units on J2310. For the NDC quantity, use the total milliliters of fluid. For example, if the EMS provider administered 3 doses of 0.4mg/1mL fluid from the vial, bill 2 units of procedure code J2310 (based on 1.2 mg) with an NDC quantity of 3 (based on 3mL).
  • ADMINISTRATION CODE: 96372 with Modifier U2 (indicating injection. NOTE: The use of an atomizer to administer the liquid form of naloxone nasally is considered “injection” for billing purposes.)

The NDC must be configured as 11 digits, using what is referred to as a “5-4-2” format. If the product label displays an NDC with fewer than 11 digits, a zero must be added at the beginning of the appropriate segment to achieve the 5-4-2 format. Hyphens and spaces are omitted when submitting the NDC number on a claim. 

No Transportation

Transportation is not required to bill for the administration of naloxone. If transportation does not occur, IHCP will reimburse EMS providers for the drug (J2310 and/or J3490) and for A0998 – Ambulance response and treatment, no transport. The IHCP considers A0998 inclusive of the drug administration if no transportation occurs and will deny the detail for drug administration if it is billed with A0998.

More Information

For more information about billing naloxone administration for EMS providers, check out IHCP bulletin BT202063 from May 19, 2020.

—  All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.