Primary Care Coding Alert

Question: We want to bill Medicare for Protonix and Pepcid given to our patients in the office intravenously. How should we go about doing that?

Alabama Subscriber

Answer: The problem with billing S0164 (Injection, pantoprazole sodium, 40 mg) for Protonix and S0028 (Injection, famotidine, 20 mg) for Pepcid is that Medicare will not pay on either code. That’s because HCPCS Codes beginning with the letter S are temporary national codes developed by Blue Cross/Blue Shield and other commercial insurances for supplies, drugs, and services not covered by Medicare.

You will need to contact your regional Medicare Administrative Contractor (MAC), who may accept billing for the drugs using J3490 (Unclassified drugs). Alternatively, your provider could opt to use another drug such as Zantac, billed with J2780 (Injection, ranitidine hydrochloride, 25 mg), which Medicare will pay for. And as a last resort, you could notify the patient before treatment that Medicare will not pay for the drug by using an advance beneficiary notice (ABN). This would shift responsibility for payment to the patient, however.