Ob-Gyn Coding Alert

Are you coding for expensive medications and medical supplies for which reimbursement doesnt even cover the cost to your practice?

According to coders and practice managers in ob/gyn practices of all sizes this problem is fairly common. John Pelligra, MD, a New Jersey ob/gyn, has been giving Rhogam in his office to pregnant Rh negative patients. The clinics cost for the injection is $73, and they have been appropriately billing for the injection using the J code J2790. But, their reimbursement is only $26-$54. Another practice in California mentions a similar experience with Depo-provera (J1000), in which they are being reimbursed only 60% of what the medication is actually costing them. A practice in Michigan reports a similar problem with the expensive medication Lupron (J1950), in which reimbursement has been so low that they were forced to ask patients to procure the medication elsewhere.

Apparently, the problem is not just with medications. Rhoda Meyers, office manager for Womens Health Center at Robinswood in Hagerstown, MD says the problem often occurs with IUDs and other expensive supplies such as pessarys (A4560). Im sure, in the past we lost a good deal of money, she adds.

So, what can you do when reimbursement for expensive medications and supplies is less than what the clinic actually paid? No matter how noble ones intentions, a practice cant stay in business if its costs exceed its reimbursement. There is no single answer, but in talking with a number of different practices who have experienced this problem here are some tips that will help coders and their practices avoid the red ink.

1. Track Expensive Items. Some ob/gyn offices we talked with werent sure if they were losing money on the big-ticket items because they had not been tracking costs and reimbursements. According to those that are tracking, its essential that you know your costs and have an invoice for the expensive items with the chart. Then, as payment comes in, you can do a quick comparison. Although practices arent making money off these items, they should at least make sure their costs are covered. Another way to check whether or not money is being lost is to go back and pull a few old charts where Rhogam or an IUD was used and see how the reimbursement came in. You may not be able to do anything about the old claims, but at least you will know whether youre losing money and where to start plugging the holes.

2. Appeal to the Payer With an Invoice. One of the simplest and most obvious ways to handle these situations, according to Meyers, is to go back to the payers. Meyers prints the claim to paper and then, actually attaches a copy of the suppliers invoice showing the payer exactly how much was paid for the item. If the item still comes back underpaid, she may contact the payer, see how they are making their calculations, and appeal to them to adjust the payment. The claims processor may have made an error, not looked at the accompanying invoice, or simply tried to underpay.

Tip: Some payers are trying to prohibit any mark-up of supplies or medication by practices and may require all such items to be initially accompanied by invoices.

3. Obtain Pre-authorization For the Prescription. While more time consuming up front, another option is to compile a list of items you are having trouble being reimbursed for and obtain pre-authorization from the payer for the specific item. If you know a patient needs a course of treatment with an expensive medication, try contacting the payer to see specifically what they will reimburse and whether or not it will cover your cost. Some payers may consider Rhogam to be part of the global ob benefit, and it would be useful to know this up front.

4. Have the Patient Procure the Medication. If the item is a medication and the patient has a prescription benefit in their coverage, you may be able to write a prescription and have the patient obtain the item through a pharmacy and bring it to your office for administration. Some practices have found this works well with items such as Depo-provera and Rhogam. Robert Brenner, MD of Pikesville, MD said, We give our patients a written prescription for the Depo and let them pick it up at the pharmacy. It is inconvenient for the patient to go the pharmacy and then come back for the injection, but our practice cant afford the secretarial time for pre-certification for a $35 item. But other practices have also found that pharmacies in their area do not stock the medication and are unable or unwilling to obtain these items. This may warrant some relationship developing with your local pharmacy.

Tip: When a patient has taken a prescription to the pharmacy for an injection such as Depo-provera and then returns to the practice for the administration of the shot, you can code for the services of giving the shot using the Therapeutic or Diagnostic Injection code 90782. You may not use the J code for the medication itself.

5. Contact the Supplier. If you are having difficultly in processing a claim for expensive medications, another option is to contact the supplier for assistance. A representative for Tap Pharmaceuticals, the makers of Lupron, said they will provide assistance to physicians in obtaining reimbursement for Lupron by calling the payer on their behalf and helping the claims processors correctly process the claims. Tap Pharmaceuticals can be reached at 1-800-621-1020. The supplier cannot process the claims for you, but this can be a big help in making sure the claim is processed correctly.

6. Alert the Patient Up Front. Once you have identified the expensive items for which there may be reimbursement problems, let the patients know up front they may be responsible for a portion (or all) of the costs. This is good business practice and allows the patient a choice without any surprises later. Kathy Johnston, reimbursement specialist with Excel Medical Management Associates in Bethesda MD, says the physicians she works with are having patients pay for IUDs up front as many dont have contraceptive benefits.

Unfortunately, Medicare requires that you accept their payment when you accept assignment, but even if you do not, you are subject to the Medicare limiting charge for the item in question.

7. Consider Not Providing the Items. Finally, some practices have stopped offering the expensive items and have found other alternatives. For example, one practice has been able to work out an agreement with the hospital that does their Rh testing and now has the injections given there. As already mentioned, some have found ways to procure medications through outside pharmacies.

Obviously, there is no one single answer for assuring reimbursement for expensive medication and supplies, and it may even be a growing problem as payers squeeze dollars and more expensive treatment options are created. But, everyone seems to agree the best place to stop losing money is to become fully aware of what you are being reimbursed and how it squares with your expenses.