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-   -   96372 with depo shot medicaid denial (http://www.aapc.com/memberarea/forums/showthread.php?t=85673)

OBcoder1984 01-11-2013 12:26 PM

96372 with depo shot medicaid denial
Does anyone know what Medicaid's rationale is for making injection code 96372 for a depo provera shot a non allowable charge? They won't pay enough for the reimbursement for the depo and they say that 96372 is non allowable (so we can't charge our patients for the injection either). Our doc was already having them bring their own depo provera, but now Medicaid won't pay for the injection fee. Now, our doc is wanting to send them to the free health clinic because they don't want to give free birth control shots. In the past, the nurses were billing the nurse visit code with the injections, but I advised them that it was inappropriate and the injection code should be used. It is causing a great deal of stress and I just want to make sure I am advising them correctly. They are sending patients to the health clinic and the health clinic is sending them back saying they have to have pap smear records or have the clinic do their pap smear before they will give the shot. Also patients are getting upset in the office. In addition, now we were told that Health Clinics may not serve patients with Medicaid since they have "insurance." I have told my doc that the only way I see is for him to see each patient prior to the injection and do counseling and document and then I can bill on time or if medical necessity warrants an exam. Doc says he just doesn't have time. He is the only doc in the office. Sure would appreciate a response from someone who has this solved!

Herbie Lorona 01-11-2013 02:54 PM

I have not had this issue with Medicaid. Did this just start this year or has this been an on going issue for you?

mitchellde 01-11-2013 03:01 PM

you are correct in that you cannot charge a 99211 for the injection, but you also cannot charge an office encounter for the physician to see the patient prior to a scheduled injection. If Medicaid has stated the injection admin in non payable with the depo J code then that is going to be the way it is, but first you need to verify that this is the problem. I have also had no issues with billing any covered drug with an administration code. Is it possible there are different issues? such as dx? Have you verified that Medicaid policy indeed states the drug is covered but the admin is not?

OBcoder1984 01-11-2013 03:12 PM

Medicaid has been denying since we changed from using the 99211 to the 96372 injection code. Our Medicaid biller said she was told it is a non-allowable charge. They deny it. We bill it with J1055 (now J1050) and V25.49. Any ideas?

OBcoder1984 01-11-2013 03:15 PM

We changed from the 99211 nurse code to the 96372 injection code about 3 months ago. My commercial payors are paying well. We bill 96372 and J1055 (now J1050) with V25.49. Any ideas?

OBcoder1984 01-11-2013 03:25 PM

Debra, I was hoping to hear from you. I really respect your advise on our posts. We bill 96372 with J1055 (now J1050) with V25.49. My Medicaid biller is the one that states that she was advised this is a non allowable code. I instructed the office in the change to the injection code and the Medicaid biller is the one that said her conference with Medicaid several months ago advised it was not allowable. I was using the Vcode that was being used along with the nurse code when I came here which was V25.49. Medicaid was paying on that with the 99211, but when I advised them we needed to change to the 96372 injection is when Medicaid began denying. I saw in another post that other billers were using V25.02 for the depo shots each visit, but that code states it is for the "initiation" of other contraceptive measures which led me to believe this would only be appropriate for the initial visit. What do you think?

Herbie Lorona 01-11-2013 03:52 PM

Yes I would definetly get in contact with them and get more info as to why exactly they are not covering that code. I haven't ran into any type of issue with the Depo shot like that.

OBcoder1984 01-11-2013 04:03 PM

Herbie, Thanks. What dx code do you use for the Injection of the Depo shot?

Herbie Lorona 01-11-2013 04:42 PM


OBcoder1984 01-11-2013 08:32 PM

Thank you. I will see if this is a dx code issue. I will give the V25.40 to our Medicaid biller. My experience is that calling Medicaid is like nailing jello to a tree, but I will indeed call. I will change my focus from the Procedure code for the injection to seeing if the dx is the problem as you and Debra advise. I would have thought the V25.40 "Contraceptive surveillance, unspecified" wouldn't best describe the visit since we know that the contraception being used is specified....depo. This has created such a disturbance in my office that I would appreciate staying connected to AAPC codng support world until this is resolved. I want to get this right. Thank you for the lifeline.

OBcoder1984 01-14-2013 08:17 AM

I checked this morning on our Medicaid website's fee schedule and they show that they pay $0 for the 96372 injection code. They will pay for the depo medication but they do not reimburse enough to pay for what our office pays for it. That is why our doc started having them bring their own depo medication. Also that is when they were billing the 99211 so they were getting paid for the visit. After I advised them that was inappropriate code and we changed to 96372, then we were getting paid only for the depo meds considerably below our cost, and when they bring their own, we get paid nothing. Any further ideas to solve this issue, would be greatly appreciated.
Addendum: I see that the depo J code was deleted starting January in the HCPCS coding book. It is now J1050. I just checked that code on the Medicaid Fee schedule website and it shows they pay $0 for that now too.

mitchellde 01-14-2013 08:39 AM

If it is on the fee schedule as a 0 reimbursement then what this tells me is that Mcaid considers the injection to be inclusive with the drug allowance. Also I see you are from the show me state! When I worked with MO Mcaid, contraception was a non covered administration (go figure!). All other types of drugs the admin was covered. However you are saying now that the fee schedule shows a 0 so that says the admin is a part of the drug. I can already assure you that you cannot appeal this with MO Mcaid if the reason is contraception. You are also correct that you cannot charge the 99211. Mcaid will pay for contraceptive pills as long as the patient obtains them from planned parenthood, and even then there is a patient responsible amount.

OBcoder1984 01-15-2013 12:34 PM

Missouri Medicaid and 96372
I just received education from Mo Medicaid today regarding the injection of Depo Provera. They advised that the injection code 96372 is a non payable and non allowable code. When I inquired as to what administration code is payable for that medicine, they had to call me back. Another educator called me and advised that according to their Provider Manual "in absence of a payable administration code, the use of 99201 or 99211 is allowable and payable." We have worked on this for several months with Medicaid and not once did they give this information to help solve our problem. It was only when I asked the question that you advised me to ask, that I made it through all of the hoops. Thank you so much for your help Debra.

tlc45801 01-18-2013 11:34 AM

We are in Ohio and found that with the "family planning only" coverage they require a physician visit for contraception 60 priors to any depo provera injection for contraception.

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