Primary Care Coding Alert

Question: Our clinics frequently provide B-12 shots as stand-alone charges with no E/M charge. We write off the charges for CPT 96372 and J3420 since they are not billable to Medicare. Can we bill theses to Medicare as a non-covered charge using condition code 21 so we can bill the patient's supplemental insurance?

Montana Subscriber

Answer: Medicare coverage of 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) in conjunction with J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg) depends on the local coverage policy of the Medicare administrative contractor (MAC). For instance, Palmetto GBA has a local coverage determination that covers 96372 and J3420 when supported by one of a limited number of diagnoses that reflect vitamin B-12 deficiency.

You should check with your MAC regarding its policy. If the patient's diagnosis does not meet the requirements for Medicare coverage or the local MAC simply does not consider the service covered under any circumstances, then instead of writing off the charges, bill the patient for the service after having him or her sign an Advance Beneficiary Notice (ABN).

Supplemental insurance only covers what Medicare covers, so don't bill the patient's supplemental insurer. Medicare Advantage plans take the place of Medicare and will sometimes cover services that Medicare does not, such as preventive visits. If the patient is enrolled in a Medicare Advantage plan, you will need to check with that plan regarding its policy on B-12 injections. Don't bill both traditional Medicare and Medicare Advantage for a service, however.

Rural difference: If your provider works in a rural health clinic (RHC), you follow different guidelines. The physician must have a face-to-face encounter with the patient before billing (which it seems like your provider did not have since you're not billing an E/M service). In an RHC, your only option is to add the charges for the B-12 administration to a face-to-face encounter within 30 days before or after the shot is administered. You'll find documentation regarding this in the CMS Rural Health Manual.