Wiki Injectable medications

[Cindy711]

The orthopedic surgeons in my office occasionally bill injection code 20550, but we have never billed the HCPCS code for the medication. The decision not to bill the supply was made by a former administrator, and nobody here knows why we would not bill. Somebody suggested it is because we need CLIA numbers, but I am not certain that we do as we bill for Xiaflex. Have we just been missing out on the supply reimbursement? Should I just start billing out the meds? Our practice is in CT if that makes a difference. Instruction regarding this will be greatly appreciated.

 

[Walker22]

The orthopedic surgeons in my office occasionally bill injection code 20550, but we have never billed the HCPCS code for the medication. The decision not to bill the supply was made by a former administrator, and nobody here knows why we would not bill. Somebody suggested it is because we need CLIA numbers, but I am not certain that we do as we bill for Xiaflex. Have we just been missing out on the supply reimbursement? Should I just start billing out the meds? Our practice is in CT if that makes a difference. Instruction regarding this will be greatly appreciated.

You would not need CLIA numbers because they are not laboratory services. I see no reason not to bill the drug code. Keep in mind that many payers bundle the J code in with the procedure code, but that shouldn't stop you from billing it. Don't forget to pay attention to units!

 

[Cindy711]

Thank you

Thank you, Walker. That is very helpful! I wondered if they were bundled.

 

[hopepg]

I would wonder if the medication is being dispensed from your clinic or from a pharmacy & the patient is only bringing it to the clinic for the injection.
Also, is the medication "billable".. If billing medication dispensed from the clinic, you would need to report the NDC data on the claim.

Some payers we bill injections for require the patient/member of that plan to obtain medication from a "Specialty Pharmacy" The patient/member will get the med & bring to clinic for the injection administration. In this scenario, we only bill the administration code & not the supply code.

Some payers don't have a requirement in where the medication is obtained but may require a prior authorization for wherever it is dispensed. In this scenario, if our clinic has prior authorization to provide the medication & injection administration procedure - we bill for both codes.

Some payers only recognize specific code/NDC combinations so you would have to check into all of that also.

There are probably other scenarios that I'm not immediately thinking of. Might depend on the various payers your provider bills & that payer's preference.

Without knowing more specifics - If your clinic is dispensing the medication, your clinic could be missing out on revenue.

If your clinic is not dispensing the medication & the former Administrator chose to bill only the injection procedure - there might have been a medication cost>reimbursement decision that went into it. The group I work for reviews this on a regular basis for the injection medications they use/administer....