OASIS Alert

Check the LCD for diagnosis code guidance.

B12 injections can require skilled nursing, but that doesn't mean the Centers for Medicare & Medicaid Services will reimburse you for providing them. Make certain your claims for B12 injections pass muster with these tips.

The Medicare Benefit Manual advises that:

"Intravenous, intramuscular, or subcutaneous injections and infusions, and hypodermoclysis or intravenous feedings require the skills of a licensed nurse to be performed (or taught) safely and effectively." Medicare will pay for these services when they are deemed "reasonable and necessary to treat the illness or injury." To meet those requirements, the medication you're administering must be accepted as safe and effective for treatment of the patient's illness or injury, and the patient must have a medical reason for being unable to take the medication orally.

Vitamin B-12 injections are considered specific therapy only for the following conditions:

Specified anemias: pernicious anemia, megaloblastic anemias, macrocytic anemias, fish tapeworm anemia;

Specified gastrointestinal disorders: gastrectomy, malabsorption syndromes such as sprue and idiopathic steatorrhea, surgical and mechanical disorders such as resection of the small intestine, strictures, anastomosis and blind loop syndrome, and

Certain neuropathies: posterolateral sclerosis, other neuropathies associated with pernicious anemia, during the acute phase or acute exacerbation of a neuropathy due to malnutrition and alcoholism.

The Medicare Benefit manual further advises that a reasonable and necessary dosage schedule for patients with pernicious anemia caused by a B-12 deficiency, would be to receive intramuscular or subcutaneous injections of vitamin B-12 at a dose of from 100 to 1000 micrograms no more often than once a month. "More frequent injections would be appropriate in the initial or acute phase of the disease until it has been determined through laboratory tests that the patient can be sustained on a maintenance dose."

Your MAC or RHHI should be able to clarify which diagnosis codes demonstrate medical necessity. The CMS website lists the following ICD-9 codes as acceptable according to the Palmetto GBA local coverage determination (LCD) for B12 injections.

ICD-9 Codes that Support Medical Necessity for B12 Injections

The key, as always, is documentation, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and

CoDR -- Coding Done Right in Denton, Texas. "The list from CMS is useful, but as long as you can show your medical need, you should be able to get coverage."

Take note: There are no codes listed under the heading "ICD-9 Codes That Do Not Support Medical Necessity," in the Palmetto B12 injection LCD, Selman-Holman points out.

Regarding documentation for B12 injections, CMS says "Documentation supporting medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary. It is expected that documentation, if requested and reviewed, will reflect abnormally low B12 levels by testing"

"Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the Intermediary upon request," CMS concludes.

You can read additional details regarding B12 injections in the Medicare Benefit Policy Manual Chapter 7 - Home Health Services 40.1.2.4 - Administration of Medications here: www.cms.gov/manuals/Downloads/bp102c07.pdf