Pediatric Coding Alert

Pediatric practices that bill for antibiotic injections have often found that Rocephin is not adequately reimbursed by insurance companies. Often, a plans payment for an injection doesnt cover the cost of the drug, much less the total cost of the administration.

One managed care company pays us $14 for an injection of antibiotics, says Phyllis Grijnsztein, RN, office manager for Kuritzkes, Grijnsztein, Resmovits, and Milman of Great Neck, NY. The cost to us is $24.90 for 500 milligrams of Rocephin. In the case of a toddler who came in recently and required 600 milligrams of the drug, Grijnsztein had to use two vials, discarding the rest of the second vial. How is a practice supposed to get reimbursed for the full cost of the medication?

The answer often lies in practice-favorable contract terms arranged with the insurance company.

1. Carve out injectables. This is a contract matter, says Peter Carson, accounts reimbursement manager for the Honolulu Medical Group, a two-pediatrician multi-specialty practice in Honolulu. With a number of medications, the injectable is carved out, says Carson, whose office is working within the constraints of a very tight managed care system. Under the carve-out, the injection is paid separately. The office visit and the administration of the Rocephin are under capitation, so they are not billed.

2. Ask the insurance company to specify the amount of drug included in its units. Sandy Farrell, insurance and billing manager for Alpharetta Pediatrics, a three-pediatrician, two-nurse practitioner practice in Roswell, GA, says that some insurance companies pay for Rocephin by the unitbut they dont define how much is in a unit. One company told me how much they pay per unit, she said. But they said, You tell me how many units you use. And, the company left it up to Farrell to determine how many milligrams are in a unit. Based on the amount that the company was paying per unit of Rocephin$20Farrell decided it was a small unit. I came up with 250 milligrams per unit, she says. The case described by Grijnsztein, in which the child required 600 milligrams, would be three units, says Farrell. This still isnt enough, because it gives Farrell $40 for two vials and that she has paid over $50 for. No plan that we know pays enough for Rocephin, she says.

3. Dont forget the J code. Both Farrell and Carson file for Rocephin using a HCPCS code. The code is J0696 . Interestingly, the J code is for 250 milligrams. Carson also adds a description from chart notes of why the Rocephin was used, and what it cost. A lot of companies act as if they cant read the J code, says Farrell. It comes back on the EOB as a zero. And they also say its covered in the office visit. But it isnt.
Unfortunately, in this case, the practice manager or reimbursement specialist is left with the chore of calling the insurance company and requesting that they re-examine their payment policy and/or update their software to read the code.

Manufacturer Recommends Carve-Out

Rocephin has been on the market for 15 years, but has only recently become a problem for pediatricians. Thats because less than a year ago the Food and Drug Administration approved the injectable antibiotic for a new indication: otitis media. Roche Pharmaceuticals, the manufacturer, says that Rocephin is a good way to combat the suboptimal dosing that sometimes occurs with oral medications in children. There are no compliance problems and no spitting up of medication, notes Charles Alfaro, spokesperson for the Nutley, NJ-based firm.

But, what about cost issues?

It is our understanding that, in general, most of the individual companies will reimburse at average wholesale price, says Alfaro. This should cover the acquisition cost to each pediatricians office.

Also, Alfaro notes that Rocephin comes in both 250- and 500-
milligram vials. Since J0696 is for 250 milligrams, the coder should put a 2 next to that code in the units field of the claim form, and then the practice can be reimbursed adequately, he says.

Or, you could put a 4 in if you use an entire gram. In most cases, he says. 500 would be appropriate.
Roche likes the carve-out idea best.

We feel that the process of carving out injectables is a fair way of providing the appropriate drug, Alfaro explains. It means that the basis for determining the appropriate antibiotic will be based on clinical rather than cost concerns.