Pediatric Coding Alert

Question: For a Rocephin injection, is it better to use J0696 or 90788? Insurers pay only a portion of the medication's cost with J0696.


Illinois Subscriber

Answer: Actually, you should submit both codes. For the injection administration, assign 90788 (Intramuscular injection of antibiotic [specify]). You should bill the Rocephin supply with J0696 (Injection, ceftriaxone sodium, per 250 mg).

Remember: Alpha-numeric codes, such as J0696, are HCPCS level II codes. You should use these codes for supplies and medications.

You should bill supply codes in addition to the procedure, not in place of it. With a Rocephin injection, 90788 covers the costs inherent in the injection administration, such as nurse work, injection preparation, syringe and bandage.

Code 90788 does not include the medication, which you should bill separately with J0696. Bill one unit of J0696 per 250 mg of Rocephin.

If an insurer does not cover the cost of the Rocephin, you have two options.

1. Appeal the payer's price. Explain that the medication charge is separate from the administration reimbursement. Indicate that the Rocephin payment needs to include the purchase price, and dollars for the office expenses noted. For vaccine reimbursement (which you can correlate to medication payment), the price should be "at least 17-28 percent above the vaccine purchase price," according to The Business Case for Pricing New Vaccines by the AAP Private- Sector Advocacy Advisory Committee. If the administration reimbursement is less than appropriate, you should renegotiate this fee.

2. Write the child a prescription for Rocephin. Send the parent to the local pharmacy to purchase the medication. When she returns with the prescription, give the injection. Of course, this recommendation's appropriateness depends on the condition's severity, the pharmacy's distance, and the inconvenience the pick-up and return places on the parent.
 
Answers to You Be the Coder and Reader Questions provided by Debbie Abel, AuD, audiologist at Northern Arizona Speech and Hearing Center in Sedona, Ariz., and owner of Alliance Audiology in Alliance, Ohio; Chip Hart, marketer for the Winooski, Va.-based Physician's Computer Company, which supports and develops pediatric-specific software to manage clinical and clerical duties for pediatric offices; Richard Lander, MD, FAAP, pediatrician at Essex-Morris Pediatric Group in Livingston, N.J.; and Jeffrey Linzer Sr., MD, MICP, FAAP, American Academy of Pediatrics representative to the ICD-9-CM editorial advisory board.