Wiki Guidance

[RadVCCoder]

I am being asked to bill out one way to commercial insurances and then another to Medicare/Medicaid patients. I am under the impression that is not compliant..... example would be that the pt is having pain injections and has commercial insurance, they want me to just bill for the injection and nothing else. However, if the pt had Medicare/Medicaid they want me to list all the drugs/medications the pt receives.

My question is, is this ethical/compliant? How do I find documentation to support this?

 

[csperoni]

There are situations where a payor policy will differ from CMS or Medicaid policy. In those situations, it is certainly compliant to bill differently for different insurances. We run into this frequently in OB regarding global maternity. Some carriers want global maternity codes. Some want antepartum and delivery/postpartum billed separately. Some want each antepartum and postpartum billed separately from the delivery only.
In your example, it seems like you are stating the patient is receiving medications injections and that your office is supplying/providing the medications. If that is the situation, why would you not bill the J codes for the medications to commercial insurances???
Is it possible that for some insurances your practice does not supply the medications and that is why you are being advised to bill only the injection???
To me, there are a couple of possibilities here with some of them being less ethical/compliant than others. If you could provide additional information about where the medication supply is coming from, that might help explain.

 

[amyjph]

Payer guidelines and policies have to be followed. It is perfectly normal and acceptable to follow that which may differ between payers/health plans and vary between CPT/CMS, etc.
Why do you think that is not correct?
I can't speak to what your specifics are regarding injections and J codes.
There are also some internal policies and procedures which are dependent on the type of practice, place of service, facility, office, etc. which can drive this process. I have seen some practices which follow and bill according to CMS across the board, while others follow each payer's rules. Some make exceptions for Work Comp. It varies.

 

[RadVCCoder]

There are situations where a payor policy will differ from CMS or Medicaid policy. In those situations, it is certainly compliant to bill differently for different insurances. We run into this frequently in OB regarding global maternity. Some carriers want global maternity codes. Some want antepartum and delivery/postpartum billed separately. Some want each antepartum and postpartum billed separately from the delivery only.
In your example, it seems like you are stating the patient is receiving medications injections and that your office is supplying/providing the medications. If that is the situation, why would you not bill the J codes for the medications to commercial insurances???
Is it possible that for some insurances your practice does not supply the medications and that is why you are being advised to bill only the injection???
To me, there are a couple of possibilities here with some of them being less ethical/compliant than others. If you could provide additional information about where the medication supply is coming from, that might help ex

We are doing Epidural and Foraminal injections, they are not wanting to bill for the medications and contrast used to commercial insurances, but after making this post and asking for more clarification from the management they are stating " Specifically they are not wanting to bill the waste". We have to for CMS but they are not wanting to for all insurances. Which I feel like could be okay?

 

[RadVCCoder]

Payer guidelines and policies have to be followed. It is perfectly normal and acceptable to follow that which may differ between payers/health plans and vary between CPT/CMS, etc.
Why do you think that is not correct?
I can't speak to what your specifics are regarding injections and J codes.
There are also some internal policies and procedures which are dependent on the type of practice, place of service, facility, office, etc. which can drive this process. I have seen some practices which follow and bill according to CMS across the board, while others follow each payer's rules. Some make exceptions for Work Comp. It varies.

For ones that do it based on each payers rules do you think they struggle keeping it all straight?

 

[amyjph]

We are doing Epidural and Foraminal injections, they are not wanting to bill for the medications and contrast used to commercial insurances, but after making this post and asking for more clarification from the management they are stating " Specifically they are not wanting to bill the waste". We have to for CMS but they are not wanting to for all insurances. Which I feel like could be okay?

This depends on if it is the facility or physician (pro-fee) billing and the place of service among other things. It also depends on if the drug wastage is even allowed to be billed or not. There are rules to it.

For example, if I am billing for the professional services of the physician, and they are performing a TFESI 64483 in an ASC let's say, I don't bill drug the facility does.

 

[RadVCCoder]

This depends on if it is the facility or physician (pro-fee) billing and the place of service among other things. It also depends on if the drug wastage is even allowed to be billed or not. There are rules to it.

For example, if I am billing for the professional services of the physician, and they are performing a TFESI 64483 in an ASC let's say, I don't bill drug the facility does.

I am sorry I should have stated that this is for an independent owned imaging center. (meaning they own and do everything)

 

[amyjph]

I am sorry I should have stated that this is for an independent owned imaging center. (meaning they own and do everything)

Ah gotcha, well CMS may not allow drug wastage for certain ones, but a commercial or other payer might. I think this is a bigger question and more going on here than we may be able to simply help with. This sounds more like an internal policy and procedure possibly and could be contract, payer, and/or facility type specific. It's hard to know for sure.