Pediatric Coding Alert

Reviewed on April 29, 2015

You can ethically increase your reimbursement for Rocephin visits if you bill for the procedure, the supply and the E/M service.

With antibiotic injection administration 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) paying only $25.39 in 2015 and ceftriaxone sodium drug cost reimbursing (J0696) at $13.35, you can't afford to lose dollars providing the shot and drug. To avoid omitting any charges, follow three steps:

1. Use 96372 for the Injection

2. Charge J0696 Per Unit

Remember that 96372 includes the administration only - you still need to bill for the supply. "You should report the Rocephin with J0696 (Injection, ceftriaxone sodium, per 250 mg) per 250 mg," Lee says.

Make sure you charge for the dose that you administer. For each 250 mg of Rocephin, you should bill one unit of J0696. List the unit(s) in the units field of the claim form next to the supply code. If you use a partial unit, such as 600 mg, round up to the next unit as shown in the dose schedule below.

Lee recommends that you bill typical Rocephin doses based on the following unit rates:

Patient receives:      Code:
250 mg                      J0696 x 1 unit 
500 mg                      J0696 x 2 units 
600 mg                      J0696 x 3 units

Challenge Antibiotic Noncoverage

Tactic: Don't accept supply denials. "If a payer refuses to pay for the supply, you should appeal for payment," Lee says. Include documentation showing the medical necessity for the injection rather than oral antibiotic use. You should also emphasize that the injection prevented the patient from requiring an emergency-department visit or hospitalization, thus saving the insurer money.

If appeals fail, consider writing a prescription for Rocephin. If you have a nearby pharmacy, the parent can pick up the antibiotic and return to your office for the injection, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. But sending the parent out to pick up the Rocephin for a very sick child may not be convenient, timely or appropriate.

3. Bill E/M That Represents Level, Time

For the evaluation, history and medical decision-making that lead you to administer the injection, you should report an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...). "In most instances, the patient comes in because he is ill and running a fever," Lee says. After examining and assessing the child, the pediatrician decides that an antibiotic injection is the best treatment.

Often, the visit may qualify for a high-level E/M, such as 99214 or 99215. Before Rocephin injections were available, these patients would usually require intravenous antibiotics in the hospital, Tuck says. "Now, we can give a shot in the office." But the level of risk associated with these cases is still high.

Because the E/M codes are bundled into 96372 based on Correct Coding Initiative (CCI) edits, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if your documentation supports both the E/M service and the antibiotic injection.