Neurology & Pain Management Coding Alert

Question: We recently hired a PA who gives injections for headaches using Toradol, Imitrex, Depo-Medrol, etc. I have been told to use 90782 for administration and the J code for medication. How should I determine how much to charge? Should I bill for an E/M code also?

Pennsylvania Subscriber

 
Answer: Code 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) is appropriate for administration of the injection with the accompanying HCPCS J code for the drug. The supply codes for Toradol, Imitrex and Depo-Medrol are J1885, J3030 and J1020, J1030 or J1040 (depending on the dose).
 
Medicare guidelines do not allow separate billing of an E/M service if only an injection is performed. Code 99211 (office or other outpatient visit) cannot be used to report a visit for the purpose of receiving an injection that meets the definition of 90782, 90783 ( intra-arterial), 90784 ( intravenous) or 90788 (intramuscular injection of antiobiotic [specify]). The Medicare Carriers Manual advises carriers, Do not pay 90782-90784 or 90788 if any other physician fee schedule service was rendered. If no E/M service or other service is provided on the same day as the injection, the injection code is billed. The drug is billed as a J code, whether the injection is separately billable or not.
 
Therefore, unless a significant, separately identifiable E/M service occurred at the time of the injection, an E/M code should not be reported in addition to 90782. If a separate E/M service did occur, report the service (i.e., 99213 office or other outpatient visit for the evaluation and management of an established patient ...) separately, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.
 
If the physician assistant (PA) bills using his or her own personal identification number (PIN), expect reimbursement at a rate of 85 percent of the total from Medicare payers. Medicare and some third-party payers may allow the injection to be billed incident to the physicians services (Medicare defines incident to as services or supplies furnished as an integral, although incidental, part of the physicians personal professional services in the course of a diagnosis or treatment of an injury or illness), using the physicians PIN. This will allow for full payment, but the doctor must be readily available and involved in the patients care. Incident to services must be carefully documented, as the Office of the Inspector General has identified incident to billing as an area for special scrutiny in 2001.
 
Note: For more information on billing incident to, see Nonphysician Practitioner Reimbursement Alert, April 2001.
 
The CMS Physician Fee Schedule specifies 0.12 relative value units for 90782, or about $5 for Medicare payers. The average fee range for all payers is $22-28, according to HealthCare Consultants 2001 Physician Fee & Coding Guide.