Pediatric Coding Alert

Reviewed on April 29, 2015

You can ethically increase your reimbursement for Rocephin visits if you bill for the procedure, the supply and the E/M service.

With antibiotic injection administration 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) paying only $25.39 in 2015 and ceftriaxone sodium drug cost reimbursing (J0696) at $13.35, you can't afford to lose dollars providing the shot and drug. To avoid omitting any charges, follow three steps: 1. Use 96372 for the Injection When you or your staff administers a Rocephin injection, you should report 96372. Code 96372 represents an intramuscular injection   Pediatricians use Rocephin, a type of antibiotic, which you may know by the generic name of ceftriaxone sodium, to treat serious bacterial infections.   CPT® deleted90782 and 90788.   2. Charge J0696 Per Unit Remember that 96372 includes the administration only - you still need to bill for the supply. "You should report the Rocephin with J0696 (Injection, ceftriaxone sodium, per 250 mg) per 250 mg," Lee says.
Make sure you charge for the dose that you administer. For each 250 mg of Rocephin, you should bill one unit of J0696. List the unit(s) in the units field of the claim form next to the supply code. If you use a partial unit, such as 600 mg, round up to the next unit as shown in the dose schedule below.

Lee recommends that you bill typical Rocephin doses based on the following unit rates:

Patient receives:      Code:
250 mg                      J0696 x 1 unit 
500 mg                      J0696 x 2 units 
600 mg                      J0696 x 3 units

Challenge Antibiotic Noncoverage Tactic: Don't accept supply denials. "If a payer refuses to pay for the supply, you should appeal for payment," Lee says. Include documentation showing the medical necessity for the injection rather than oral antibiotic use. You should also emphasize that the injection prevented the patient from requiring an emergency-department visit or hospitalization, thus saving the insurer money.

If appeals fail, consider writing a prescription for Rocephin. If you have a nearby pharmacy, the parent can pick up the antibiotic and return to your office for the injection, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. But sending the parent out to pick up the Rocephin for a very sick child may not be convenient, timely or appropriate. 3. Bill E/M That Represents Level, Time For the evaluation, history and medical decision-making that lead you to administer the injection, you should report an office visit (99201-99215, Office or other outpatient visit for [...]