Pain Management Coding Alert

Question: Our physician wants to begin administering Imitrex injections (code J3030) for some patients being treated for migraine. I haven’t been able to find a fee schedule, so what should I charge Medicare?

Pennsylvania Subscriber 

Answer: You are correct; J3030 (Injection, sumatriptan succinate, 6 mg) has no fee schedule listed in the Medicare ASP Drug Fee Schedule. 

Before filing the claim, start by checking with your Medicare contractor to make sure they cover the code. Medicare typically does not cover J3030 because it is considered to be “self-administered.” Information in the Medicare Benefit Policy Manual states that, “The program covers drugs that are furnished ‘incident-to’ a physician’s service provided that the drugs are not usually self-administered by the patients who take them.” The Manual goes on to explain that fiscal intermediaries, carriers, and Medicare Administrative Contractors (MACs) can apply an exclusion for drugs that usually are self-administered by the patient. “Each individual carrier must make its own individual determination on each drug.” 

Since there is no fee schedule attached to the code, submit your invoice for the cost of the drug with the claim for J3030. It’s really up to your practice to determine a fee for the drug, but that doesn’t mean Medicare will pay the entire cost.