Urology: Prevent Claim Problems by Applying New BCG Code

HCPCS code for BCG to treat bladder cancer

Urology coders who report BCG had an important code update July 1, 2019. Make sure you’ve made this important code swap and understand the new rules for accurate reporting of this bacteria-based immunotherapy.

Replace J9031 With J9030 for BCG

One use of Bacillus Calmette-Guérin, more commonly known as BCG, is bladder cancer treatment. The provider instills this immunotherapy into the bladder via a tube or catheter. BCG uses Mycobacterium bovis, which is bovine tuberculosis. The bacteria are reduced to minimize harm to the patient, but the bacteria are still live.

Here’s how your HCPCS coding has changed for BCG used to treat bladder cancer:

  • Before July 1, 2019: J9031 (BCG (intravesical) per instillation)
  • July 1, 2019, and later: J9030 (BCG live intravesical instillation, 1 mg).

Pay Attention to the Addition of ‘1 mg’

The biggest change for your BCG reporting is that rather than reporting J9031 “per instillation,” you now should be reporting J9030 using 1 billing unit per 1 mg used. Medicare’s rate for J9030 in the July 2019 average sales price (ASP) file is $2.821 per mg. One vial of BCG has 50 mg, so payment for a full vial (50 mg x $2.821/mg) is about $141.05.

Tip: The American Urological Association (AUA) notes that BCG is a single-use vial, so be sure to follow payer rules on appending modifier JW (Drug amount discarded/not administered to any patient) to the code for any portion not used. The AUA adds that BCG shortages have resulted in some practices opting for split-vial dosing from these single-use vials. For more information on how rules from Medicare, states, and more may affect your practice’s use and reporting of BCG, check out the BCG update from the AUA.

Pair J9031 With 51720 for Bladder Instillation

When reporting BCG use for bladder cancer treatment, be sure to include the appropriate procedure code on the claim. A likely option is 51720 (Bladder instillation of anticarcinogenic agent (including retention time)).

The July 2019 Medicare Physician Fee Schedule (MPFS) sets a national facility rate of $45.77 for professional services in a facility and $86.49 for professional services in the office.

If the provider performs the service in a facility, then the facility may be the one that pays for and gets reimbursed for the BCG. Only claim reimbursement for the BCG if your practice supplied it.

Remember: Be sure to append the appropriate ICD-10-CM code based on the documentation, such as D09.0 (Carcinoma in situ of bladder).

Final note: CPT® includes 90586 (Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use), but it’s excluded from the MPFS. Use J9030 for claims to Medicare and payers that follow Medicare rules.

What About You?

Have you been keeping up with quarterly HCPCS updates? Do you have any tips for practices considering using single-dose vials for multiple patients?

About 

Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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