Pediatric Coding Alert

Question: An insurer denied a Rocephin shot that I reported as JO696 with a diagnosis of ROCE. The pediatrician gave the shot for an ear infection. Did I use the right supply and diagnosis code?


Virginia Subscriber

Answer: No, you should refile the claim with J0696 and the appropriate otitis media diagnosis. Take these corrective steps:

1. You should report the Rocephin as J0696 (Injection, ceftriaxone sodium, per 250 mg), not JO696. HCPCS codes, such as J0696, contain one letter and four digits. So make sure you code the numeral "0" rather than the letter "O."

2. For the diagnosis, you should report the reason the pediatrician gave the shot. Because the patient had an ear infection, link J0696, as well as the injection code (90788, Intramuscular injection of antibiotic [specify]), to an otitis media diagnosis, such as 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum).

Tip: Avoid using the nonspecific OM code 382.9 (Unspecified otitis media), which may trigger a denial for nonspecificity.

3. Verify that you charge the right dose amount. Bill one unit of J0696 for each 250 mg the pediatrician administers.

If, after you submit a corrected claim, the payer still refuses to pay for the supply, appeal. With the appeal, include documentation showing the medical necessity for the injection rather than oral antibiotic use. Also emphasize that the injection prevented the patient from requiring an emergency-department visit or hospitalization, thus saving the insurer money.

For insurers that reject multiple appeals, the pediatrician may want to 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. But sending the parent out to pick up the Rocephin for a very sick child may not be convenient, timely or appropriate.

 - Answers to You Be the Coder and Reader Questions provided by Victoria S. Jackson, CEO of Southern Orange County Pediatric Association with 11 pediatric offices in California; Kevin Perryman, practice administrator at Primary Pediatric Medical Association PA in Kerrville, Texas; Julia M. Pillsbury, DO, FACOP, FAAP, a pediatrician at the Center for Pediatric Medicine in Dover, Del.; Lorna Powell, CCS-P, owner of Quality Medical Management in Elk City, Okla.; and Linda Walsh, MAB, senior health policy analyst with the American Academy of Pediatrics Division of Health Care Finance and Practice.