December 2000 Bulletin

Don’t forget injectable medications

Document what was injected in medical record and on fee slip, too

By Margie Scalley Vaught

Orthopaedic offices could be losing revenue if they are not reporting supplies and materials used, especially injectable medications.

It is not uncommon for a provider to perform an injection on a patient and not list the medication used on the fee slip. Providers need to document what was injected into the patient not only in the medical record, but also on the fee slip. If this information is omitted, the medications are usually not billed out. Rarely does the office staff have the time to go and look for dictation to find out if injectable medication were used and what kind.

Every office should have a HCPCS National Level II coding book. These books should be updated yearly just like your CPT and ICD-9 books because changes occur in the HCPCS books similar to those in the CPT and ICD-9.

Most of your injectable medication can be located in the J category. Orthopaedic surgeons usually have particular injectable medications that they use for their joint injections, tendon sheath injections, etc. These injectable medications need to be matched with the appropriate HCPCS code so that reimbursement may take place. The index in the back of the HCPCS book has injectable medications located by generic and/or name brand.

Providers need to make sure that they notify the billing office, via the fee slip, what medications were injected and how much. Let’s say that a provider does a knee injection using prednisolone 80mg. The corresponding HCPCS code is J1690, which is listed as "Injection, prednisolone tebutate, up to 20mg." In this case it would be billed out J1690 and in the units section of the HCFA 1500 form the number 4 would be placed to indicate that 80mg was given.

Setting the fee for injectable medication usually is generated by the cost the provider incurs to obtain the product. When the invoice is received, this amount can be determined. If the office is receiving the injectables in bulk form it is recommended that they divide the dollar amount by what the HCPCS code indicates per injection. In the case just mentioned, if some brands of prednisolone come in 120mg vial and cost $30 per vial (this is an example only not to reflect the actual costs), and since J1690 states that it is for 20mg, you would divide that 20mg into the 120mg and see that it would amount to six injections, per HCPCS coding. This would indicate that for each 20mg injection it cost the provider approximately $5. Using the earlier example, the billing would reflect a $20 charge for injectable medications. You can see that even though you are talking about $5 per 20mg injection, it adds up.

If you find that insurance carriers are reimbursing lower than your actual cost (including shipping and handling) for the medication, send them a copy of the invoice along with a cover letter pointing out the fact that they are not even covering the costs.

Some injectable medications are quite expensive and reimbursement is quite low. In those cases some offices have elected to have the patient purchase the medication via a prescription and then they bring the injectable medication to the office for administration. Medicare has not yet taken a stand on this practice, but it is expected that they will be addressing this in the near future. Many of the patients that require costly injectable medications are in the Medicare population, and it then becomes an out-of-pocket expense for the patient.

If your office currently does not have a list of all the injectable medications that are used and the quantity injected, this needs to be established. Once this list is completed, matching it with the appropriate HCPCS code is the next step.

Performing internal audits, which match office notes with bills, can help offices track any missed injectable medications as well as other supplies and materials.

However, the most important element in billing injectable medications lies with the provider. If the provider fails to document the drug name and the amount in the medical record and the fee slip, billing most likely cannot occur.

Margie Scalley Vaught, CPC, is an independent coding specialist in Ellensburg, Wash. She also is a member of the American Academy of Professional Coders National Advisory Board.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.

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