Eli's Rehab Report

Answer: Enbrel is a self-injectable drug, and because of that, you probably wont be able to request reimbursement, despite the fact that the patients shoulder injury prevents her from injecting herself. Section 2049 of the Medicare Carriers Manual states, drugs that are self-administered are not covered by Medicare Part B unless the statute provides for such coverage ... if a physician gives a patient an injection that usually is self-injected, this drug is excluded from coverage, unless administered to the patient in an emergency situation (e.g., diabetic coma).

Medicares rationale is that a primary caregiver should be available to perform the injections if the patient is unable to. If a caregiver is not available and the patient receives the injections in the physiatrists office, the patient is responsible for payment.

Many local Medicare providers allow clinicians to bill for the administration of self-injectable drugs on a one-time-only basis at the initiation of the therapy, if the drug requires dose titration to test the patients responsiveness and appropriate dosage, or if the physiatrist is demonstrating how to administer.

In some instances, a patient will bring his or her own drug to the office for injection, and the drug is not classified as self-injectable (such as epoetin). In these cases, you can bill for it. If the RN administers it, use CPT 99211 (office or other outpatient visit). If the physiatrist performs the injection, use the appropriate injection code (e.g., 90782, 90788, etc.). In addition, code the drug itself (e.g., Q0136 is for epoetin), but with a zero dollar amount in the charges column of the HCFA 1500 form with a notation that the patient provided it.