# viscosupplementation injections



## rachlowe (Feb 25, 2009)

We have a physician who would like to give viscosupplementation injections in his practice.  However, this drug is very expensive and the reimbursement doesn't cover the expense.  To administer this drug it must go directly into the joint, so the physician would bill a 20610.  We have thought about writing the patient a script and having them purchase and supply their own drug.  I don't see why this would be a problem, other then the fact that the patient will be paying for this drug at the pharmacy out-of-pocket for a covered service.  

Anyone have an opinion on this?


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## Lisa Bledsoe (Feb 25, 2009)

*I am interested in comments also*

We are currently conducting an in-house study and audit to make sure we are capturing all costs involved.  I'm interested to see what others have to say as well!
Lisa


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## mmorningstarcpc (Feb 25, 2009)

Rmilley,

My practice actually did something similar years ago.  When MMR was first being used for teens/adults, the adult dose was not covered by most insurances, or what reimbursement we did get did not cover our cost.  We checked with several large insurance companies in our area and found out that the patient's could use their pharmacy benefits and it would be covered.  We just then administered it and charged admin fee.  Hope that may help.


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## RebeccaWoodward* (Feb 25, 2009)

Well...I have alot of experience with this. Good and bad.  I *highly* recommend that you review each carrier's policy regarding the criteria that must be met in order for the service to be deemed medically necessary.  I can tell you, without a doubt, that BCBS is the WORST carrier for denying this procedure.  An example of our BCBS' policy is......

For the treatment of pain in osteoarthritis of the knee when conservative treatment has failed. The medical record must document conservative therapy as follows:
1. Diagnosis of osteoarthritis substantiated by x-ray or other imaging or arthroscopic findings, and

2. Complaints of persistent pain while using simple analgesics and non-steroidal anti-inflammatory drugs, and

3. Aspiration of the joint resulting in clear viscous aspirate, when effusion is present, followed by injection of steroid that results in unsatisfactory relief of pain or relief of pain that lasts less than three months.

B. Repeated courses of intra-articular hyaluronan injections may be considered medically necessary under the
following conditions:

1. Significant pain relief was achieved with the prior course of injections; and

2. At least six months have passed since the prior course.

I can't tell you how many claims they have denied over and over and over...
Needless to say, all were appealed and _most_ were paid.  Getting the physicians to remember these policies and adhere to them was somewhat difficult in the beginning.  I have recommended the physicians to write a script and we are still tossing this back and forth since there is so much red tape.  I wish you the very best.


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## rachlowe (Feb 25, 2009)

Thanks Rebecca,
My concern is with Medicare.  Have you ever been in the situation where the patient brought their own drug and you only billed the admin?  How do you think Medicare would feel about this patient paying for their own drug at the pharmacy when if they received it in our office it would have been allowed?  I'm not comfortable with that and would appreciate your opinion.


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## RebeccaWoodward* (Feb 25, 2009)

We haven't had any Medicare patient's present to the office with the medication.  I can say that our Medicare contractor pays promptly when the claim is submitted with the required diagnosis (and medical necessity documented, of course).  It is accurate to say that this, typically, is not a money making procedure.  We looked at all the different aspects of keeping this "in-house".  We are multi-specialty, (family, internal, urgent care, occupation/wc, ortho, neuro, pain mgmt, and infertility) therefore, we can (or try) to send our ortho patient's to our other practices for those particular problems.  Also, there are only a couple of ortho practices in our city so there is a competition, per se, for these patients. We, also, keep mind our ancillary services that we can keep in-house, thus increasing revenue. Now, as far reimbursement, the payments are all over the place.  Some carriers reimburse very low and some very high.  We do keep an eye on these payments and for the most part, we come out even.  It was our thought that we would do it one way for all carriers, without exception.  In the case of a Medicare patient, if the procedure is being provided for a non-medical necessity, we get an ABN up from if the patient wishes to continue with the treatment. We continue to purchase this product since there were more positives then negatives.


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