CODING & REIMBURSEMENT FREQUENTLY ASKED QUESTIONS

The most asked questions about coding & reimbursement for Venofer

Venofer Reimbursement Brochure and Patient Assistance Program

Venofer Reimbursement Brochure and Patient Assistance Program

This guide provides information about general coverage, coding, and reimbursement to help healthcare providers understand the policies of the Medicare program and other third-party payers. Information is also provided on the VenAccess™ Patient Assistance Program.

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Buy and Bill for Venofer and all other non-self-injected drugs means, as a general matter, that your practice or clinic can purchase the drug from a distributor, provide/administer the drug to a patient, and bill for the drug.

Bagging" generally means that a third party—eg, a pharmacy—provides the drug either to the patient or to the treating health care provider, as opposed to the health care provider receiving the drug from the treating health care provider.

a. "Brown Bagging" is when a patient's insurance company instructs a specialty pharmacy to ship the drug to the patient and the patient brings the drug to their chosen healthcare facility for administration to the patient. When insurance companies do this, they do not reimburse the healthcare facility for the cost of the drug because the drug was already purchased from the specialty pharmacy and, therefore, the provider does not need to be reimbursed for the drug.

b. "White Bagging" is when a patient's insurance company (rather, the insurer’s designated specialty pharmacy) ships the drug to the patient's chosen healthcare facility for administration to the patient. Similar to brown bagging, insurance companies do not reimburse the healthcare facility for the cost of the drug because the drug was already purchased from the specialty pharmacy and, therefore, the provider does not need to be reimbursed for the drug.

c. "Clear Bagging" is when a patient's chosen healthcare facility offers its own pharmacy, and the provider accesses the drug from that pharmacy rather than a distributor. This happens either because the patient has only a pharmacy benefit and no major medical benefits (for office-based infusions) or the drug is only covered under the pharmacy benefit.


That largely depends on the patient’s insurance company and the benefits outlined in their policy. As a general matter, the patient must have a major medical benefit in their policy. Medicare Parts A and B, Medicare Advantage, and most Medicaid plans cover intravenous drugs (such as Venofer) under the medical benefit. It’s important that you verify whether the patient has any of these benefits EVERY TIME the patient arrives for a Venofer infusion. Patients can become temporarily or permanently uninsured if they forget to pay their insurance premiums, change jobs, or become unemployed. Commercial insurance, Medicaid, and Medicare Advantage patients can secure prior authorization before treatment. This will provide them with some peace of mind that Venofer is covered by their insurance plan.

According to a recent study by the American Medical Association (N=2,000 physicians),1 >50% of physicians reported treatment delays due to complications with obtaining prior authorization. These problems are not unique to Venofer, other drugs, or any other billable product or service.

CPT codes are used to bill for services provided by physicians' offices and other outpatient facilities. Venofer requires various injection and/or infusion times for the 100 mg, 200 mg, 300 mg, and 400 mg doses. Below is a table of common CPT codes that providers often use:*

CPT code CPT code descriptor
96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug (15 minutes or less)
96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, separate or sequential substance/drug (15 minutes or less)
96365 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial up to 1 hour (16-90 minutes)
96367 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); separate or sequential substance/drug (16-90 minutes)
96366 Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour, up to 8 hours (list separately in addition to code for primary procedure; 30 minutes into the next hour)
*It is always the provider’s responsibility to determine the appropriate health care setting and to submit true and correct claims for actual products and services rendered. Providers should contact third-party payers for specific information on their coding, coverage, payment policies, and fee schedules.

HCPCS codes are used to identify most drugs and biologics. Venofer® (iron sucrose) injection, USP has been assigned the following drug-specific HCPCS code (also known as a J-code):
J1756 Injection, Iron Sucrose, 1 mg
Each 1 mg of Venofer is equivalent to one (1) service unit. When billing for quantities greater than 1 mg, indicate the total amount used as a multiple of service units on the claim form. Service units are very important and must be included on every claim.
Here are some Venofer examples:

• One (1) vial (2.5 mL) or 50 mg = 50 service units
• One (1) vial (5 mL) or 100 mg = 100 service units
• One (1) vial (10 mL) or 200 mg = 200 service units


Many payers require NDCs for claims. These payers include, for example, Medicaid, United Healthcare, and some of the “Blues” (ie, Blue Cross Blue Shield, etc). NDCs can be found on the Venofer website or at BuyandBill.com. The NDC for Venofer (and all drugs) should be applied to the claim in a 5-4-2 format, meaning that there should be 5 digits, then 4 digits, then 2 digits on the claim, like this:

XXXXX-XXXX-XX

Venofer is preservative free and available as 50 mg/2.5 mL single-use vials, 100 mg/ 5 mL single-use vials, and 200 mg/10 mL single-use vials.
NDC Vial Size
00517-2325-10 2.5 mL Single-Dose Vial (50 mg) (10/pack)
00517-2340-10 5 mL Single-Dose Vial (100 mg) (10/pack)
00517-2340-25 5 mL Single-Dose Vial (100 mg) (25/pack)
00517-2340-99 5 mL Single-Dose Vial (100 mg) (10/pack) Premier ProRx
00517-2310-05 10 mL Single-Dose Vial (200 mg) (5/pack)

An MUE is a Medically Unlikely Edit used by Medicare and other payers. Many drugs and services have MUEs. The MUE for Venofer in both physicians’ offices and outpatient hospitals is a dose of 500 mg or more in 1 single day. It can be unusual for that kind of dosing to be administered. But when administered for a medically necessary reason, MUEs can be appealed to your Medicare contractor or other payer. Some commercial payers use Medicare’s MUEs; others have their own edits that they may or may not publish in their provider bulletins. Check with your most frequent payers.

In an outpatient hospital setting, especially one where patients are covered by traditional Fee For Service Medicare, drugs that cost Medicare under $130 per day are not separately paid. They are covered as medically necessary but are packaged with drug administration fees. This process can't be appealed because it's part of Medicare's Hospital Outpatient Payment System design.

Underpayments happen mainly when a CHARGE is less than an ALLOWABLE. Medicare and many other insurers pay the CHARGE or ALLOWABLE, whichever is the lesser. Underpayments can also happen when commercial payers adjust their payment formulas without publishing a notice. Please check with your state insurance office for more information.

There are a lot of Claim Adjustment Reason Codes and they can be hard to distinguish because some of them are close in meaning. Interpreting what's meant by each code can sometimes feel more like an art than a science. For example, CARC codes 225, 226, 251, and 252 are all requests for additional information or documentation. Surely enough, payers use them interchangeably.

The Venofer Patient Assistance Program may be able to help. Please call 1-877-4-IV-IRON (1-877-448-4766) or go to www.venofer.com for more information.