Question Ketamine Therapy and Observation

eariddell

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Torrance, CA
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Hi,
Does anybody know the way to get reimbursed for the mandatory observation after administration of Sprevata or Ketamine infusion for depression or PTSD? I have the website from the manufacturer but that shows to use an E/M Code with a prolonged services code along with the injection (which is a miscellaneous medication). It seems nobody pays for the observation codes. Please help me figure this out or let me know if you have seen this reimbursed.

Thank you in advance for your help.

 
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Hi,
Does anybody know the way to get reimbursed for the mandatory observation after administration of Sprevata or Ketamine infusion for depression or PTSD? I have the website from the manufacturer but that shows to use an E/M Code with a prolonged services code along with the injection (which is a miscellaneous medication). It seems nobody pays for the observation codes. Please help me figure this out or let me know if you have seen this reimbursed.

Thank you in advance for your help.

I was going to ask this same exact question. I have been fighting to get claims paid. We had a meeting with the Spravato rep and were told to bill a certain way. I doesn't work. We were told to bill the E/M and then the prolonged codes (99212+99415+99416). I've already had 3 claims time out! Did you ever find the answer to this? I am desperate.
 

SharonCollachi

True Blue
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Clovis, CA
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A lot of commercial insurances don't pay for extended time. If you're billing under the new method of time only on the E&M codes with the new extended time codes (99417 or G2212), you're more likely to get paid.

Now, having said that, the time is only for a licensed provider's time. It is not for the patient to sit in the office and have a medical assistant check on them every now and then.
 
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We are billing Medicare and Medicaid. The Spravato guy did not know what he was talking about then. We were told no G-codes and to use our usual 992XX code because we are not purchasing the ketamine outright and only administering. The ketamine is obtained through a pharmacy instead of us having our own supply. He also said to use the 99415 and 99416 prolonged codes and that we could use them as long as the observation was done by staff with the provider there to supervise. We haven't been able to find anything to the contrary, either. Thank you so much for the answer. I'm going to share it with my boss and coworker and see if we can clean up the mess!
 

Ayau

New
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Kuna, ID
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We are billing Medicare and Medicaid. The Spravato guy did not know what he was talking about then. We were told no G-codes and to use our usual 992XX code because we are not purchasing the ketamine outright and only administering. The ketamine is obtained through a pharmacy instead of us having our own supply. He also said to use the 99415 and 99416 prolonged codes and that we could use them as long as the observation was done by staff with the provider there to supervise. We haven't been able to find anything to the contrary, either. Thank you so much for the answer. I'm going to share it with my boss and coworker and see if we can clean up the mess!
You can bill Medicare the G-code if your office is purchasing the spravato. G2083-greater than 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation. G2082-up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation. Otherwise no, we just bill office visit. We used to bill office visit with 99354 and insurance would pay except for Medicaid, but Medicare did pay in 2020. As of today you cannot bill the 99354 with office visit. I hope this helps. Insurance pays >$1k for the G2083 and $750 for G2082.
 
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