04/14/2026

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April 2026 Frequently Asked Questions

Question

We are getting a lot of nurse practitioners and physician assistants being added to the practices does anyone have good articles on what they can and can not bill and when to use incident to and when to bill under themselves. 

I do understand incident to physicians have to be on site etc… but can a nurse practitioner do services without the physician readily available and bill under their ID alone . Can they supervise infusion?  Can they see new patients without physicians being any part of it? 

Answer

Guidance for “Incident to” Billing under Center for Medicare & Medicaid services (CMS)

Incident To Services & Supplies | CMS

Question

We have started offering Keytruda Qlex prior to having a permanent HCPCS code. We are experiencing some challenges with reimbursement from various payers with the temporary HCPCS codes.  I'm reaching out to get some guidance on this topic.

Answer

Temporary or miscellaneous codes trigger manual review because Payers can’t auto-adjudicate claims without a permanent J‑code.  

• Many plans require NDC-level billing for new products.
• Coverage policies may not yet list the new formulation.
• Claims often deny for “not otherwise classified” or “insufficient information.”
• Medicare MACs may require supporting documentation for each claim.

This is normal for new oncology products and new formulations of existing drugs like Keytruda.

Depending on the product’s status, payers may require:

• A C-code (if CMS assigned one for OPPS)
• A J‑code miscellaneous (e.g., J3490 or J3590)
• An unclassified drug code for commercial plans

If different payers require different codes, you may need payer‑specific billing sheets.

Most payers require:

• 11‑digit NDC
• NDC units
• WAC or ASP pricing support
• Invoice or acquisition cost documentation

This is often the single biggest factor in getting claims paid during the temporary period.

Many plans publish temporary billing instructions for new oncology products. These may include:

• Required temporary HCPCS code
• NDC billing format
• Prior authorization requirements
• Medical necessity documentation

If you haven’t already, it’s worth reviewing your top payer interim billing instructions.

Because claims are manually reviewed, documentation matters more than usual:

• Diagnosis and staging
• Treatment plan and rationale
• Dose calculation
• Drug acquisition documentation

This reduces denials for “insufficient information.”

Most organizations see a spike in denials until the permanent code is active. Appeals should include:

• Clinical justification
• NDC and invoice
• FDA approval letter (if relevant)
• Any payer-specific interim guidance