Ob-Gyn Coding Alert

"In the ob/gyn setting, patients are often treated for a variety of complaints through a series of injections as therapy. Injections include everything from birth control (Depo-Provera) and hormone replacement to infertility and ectopic pregnancy management. The nuances of injection coding and the accompanying evaluation and management (E/M) visits present challenges to ob-gyn coders. Injections are always a problem, says Thomas Kent, CMM, CPC, principal of Kent Medical Management, a practice management and coding consulting firm in Dunkirk, Md. It can be difficult to gain precertification, and precertification does not guarantee payment. Payment, when received, can be below the cost of supplies.

Properly Code Injections for Birth Control

Ob/gyns who try to bill Medicare and many private carriers for injections of Medroxyprogesterone acetate (brand name Depo-Provera) for contraceptive use are likely to run into as many denials as paid claims. Although the drug has other noncontraceptive uses, including treatment for irregular periods codes 626.0 (absence of menstruation), 626.1 (scanty or infrequent menstruation), 626.2 (excessive or frequent menstruation) or 626.4 (irregular menstrual cycle) Medicare and most commercial carriers will not pay for its use as a method of contraception.

When used for contraception, Depo-Provera is administered in-office every 12 weeks. If the injection is administered by a nurse, physician assistant or nurse
practitioner, the E/M code 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) can be coded as long as the medical record shows adequate documentation that a minimal E/M service was provided. Some practices also attempt to code for the therapeutic injection using 90782 (therapeutic, prophylactic or diagnostic injection [special material injected]; subcutaneous or intramuscular), but many carriers will not pay for both the E/M and injection codes together. Practices can also code for the supply, in this case J1055 (injection, medroxyprogesterone acetate for contraceptive use, 150 mg). If the patients insurance does not recognize Depo-Provera injections as a covered charge, the patient is billed directly for the service.

Note: Medicare does not cover the cost of Depo-Provera injections when used as a contraceptive.

One way of offsetting cost to the patient for Depo-Provera injections is to have the patient procure her own supplies. In other words, a prescription is written for Depo-Provera, which the patient then has filled at her pharmacy. She returns to the ob/gyn office with the drugs for injection. If the patient has prescription coverage as part of her insurance benefits, and the insurance company does not exclude Depo-Provera from coverage, this may be one way to lower the cost of the injection. Although an inconvenience to the patient, she may be able to save the difference on the covered rate of the drug versus the out-of-pocket expense of having the Depo-Provera supply come from the office. Additionally, because the cost to the practice for the Depo-Provera supply often exceeds the reimbursement rate from carriers that will pay for it, many practices find they fair better financially if the patient supplies her own injectables.

Bear in mind that when the patient takes a prescription to the pharmacy for an injection such as Depo-Provera and then returns to the practice for the administration of the shot, the practice can code for the services of giving the shot using the E/M code or the therapeutic or diagnostic injection code 90782 (but usually not both as discussed above). The J code for medication cannot be used, because the office that administered the shot did not supply it.

Administering RhoGAM Injections

When Depo-Provera is used for reasons other than birth control, Medicare will cover it. The same codes are used for the visit or the therapeutic injection, but the supply code is different. Code J1050 (injection, medroxyprogesterone acetate, 100 mg) is for noncontraceptive uses of the drug. Note that with each injection visit, the appropriate diagnostic code must accompany the claim for the injection (e.g., 626.8, dysfunctional uterine hemorrhage).

Other drugs are often injected during pregnancy to ease side effects of the pregnancy or prevent miscarriage or problems for the fetus. One such drug is RhoGAM, an Rh-immune globulin. RhoGAM injections are administered when Rhesus (Rh) incompatibility is found in an ob patient, meaning the mother is Rh negative and the baby is Rh positive. When Rh incompatiblity occurs the maternal blood produces antibodies against the blood cells in the fetus. When these antigens cross the placenta, they begin destroying fetal blood cells, causing hemolytic anemia (283.0). The destruction of the babys blood cells causes a rise in bilirubin levels. Very high levels of this substance can cause brain damage, cerebral palsy and even the babys death if untreated. RhoGAM, however, essentially blocks the formation of high levels of anti-Rh antibody and protects subsequent pregnancies from developing problems.

Effective in 1999, CPT added a new code group for immunoglobulin products, including RhoGAM. Per CPT, coders should report 90782 (therapeutic or diagnostic injection) for the injection procedure and 90384 (Rho[D] immune globulin [RhIG], human, full-dose, for intramuscular use) for the supply. For Medicare patients, bill using J2790 (injection, Rho [D] immune globulin, human, one dose package) instead of 90384. Some non-Medicare payers may require the J code as well, so you should check with the carrier first to avoid unnecessary delays. The visit at which the RhoGAM was administered would not normally be billed separately from the global package service, but the injection procedure and injectable should always be billed separately.

Billing for Vitamin B-6

Some physicians have found that vitamin B-6 injections help alleviate much of the vomiting and nausea that accompanies many pregnancies in the early stages. But no HCPCS code exists for the drug supply. We have been billing J3490 (unclassified drugs) because we cannot find a HCPCS code that describes B-6 injection, says Karen Kirby-Robinson, CPC, insurance and billing coordinator with Carolina Womens Wellness Center, a two-physician ob/gyn practice in Albemarle, N.C. Kirby- Robinson says that a lot of commercial carriers are reimbursing if the practice provides a description of the drug, but Medicaid rejects the code, stating that it is an invalid procedure code.

This is another situation when the physician might benefit from writing a prescription for the injectable with the patient returning to the practice for the shot, thus billing only for 90782 and possibly an E/M visit if one has been documented. Again, many payers are likely to deny 90782 as incident to the E/M visit. Another option is to prescribe vitamin B-6 in pill form, which the patient can obtain at a pharmacy and self-administer.

Ultimately, with these and other injectables, ob/gyn practices will have to engage in some trial and error when billing different carriers. Practices should attempt to obtain precertification for any series of drug injections they administer and make sure the patient understands and agrees to potentially absorb some of the cost of care."