Ob-Gyn Coding Alert

Are you coding for expensive medications and medical supplies for which reimbursement doesnt even cover the cost to your practice?

According to coders and practice managers in ob/gyn practices of all sizes this problem is fairly common. John Pelligra, MD, a New Jersey ob/gyn, has been giving Rhogam in his office to pregnant Rh negative patients. The clinics cost for the injection is $73, and they have been appropriately billing for the injection using the J code J2790. But, their reimbursement is only $26-$54. Another practice in California mentions a similar experience with Depo-provera (J1000), in which they are being reimbursed only 60% of what the medication is actually costing them. A practice in Michigan reports a similar problem with the expensive medication Lupron (J1950), in which reimbursement has been so low that they were forced to ask patients to procure the medication elsewhere.

Apparently, the problem is not just with medications. Rhoda Meyers, office manager for Womens Health Center at Robinswood in Hagerstown, MD says the problem often occurs with IUDs and other expensive supplies such as pessarys (A4560). Im sure, in the past we lost a good deal of money, she adds.

So, what can you do when reimbursement for expensive medications and supplies is less than what the clinic actually paid? No matter how noble ones intentions, a practice cant stay in business if its costs exceed its reimbursement. There is no single answer, but in talking with a number of different practices who have experienced this problem here are some tips that will help coders and their practices avoid the red ink.

1. Track Expensive Items. Some ob/gyn offices we talked with werent sure if they were losing money on the big-ticket items because they had not been tracking costs and reimbursements. According to those that are tracking, its essential that you know your costs and have an invoice for the expensive items with the chart. Then, as payment comes in, you can do a quick comparison. Although practices arent making money off these items, they should at least make sure their costs are covered. Another way to check whether or not money is being lost is to go back and pull a few old charts where Rhogam or an IUD was used and see how the reimbursement came in. You may not be able to do anything about the old claims, but at least you will know whether youre losing money and where to start plugging the holes.

2. Appeal to the Payer With an Invoice. One of the simplest and most obvious ways to handle these situations, according to Meyers, is to go back to the payers. Meyers prints the claim to paper and then, [...]