Pharmacy Question for the Week of September 3, 2018

Question:

Will Medicare issue payment when the main reason for a patient’s visit is to receive an injection?

Answer:

Here’s what the Centers for Medicare & Medicaid Services (CMS) states in the Medicare Claims Processing Manual, Chapter 17—Drugs and Biologicals, section 20.5.7–Injection Services. (This chapter is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf.)

“Where the sole purpose of an office visit was for the patient to receive an injection, payment may be made only for the injection service (if it is covered). Conversely, injection services (codes 90782, 90783, 90784, 90788, and 90799) included in the Medicare Physician Fee Schedule (MPFS) are not paid for separately, if the physician is paid for any other physician fee schedule service furnished at the same time. Pay separately for those injection services only if no other physician fee schedule service is being paid. However, pay separately for cancer chemotherapy injections (CPT^® codes 96400-96549) in addition to the visit furnished on the same day. In either case, the drug is separately payable. All injection claims must include the specific name of the drug and dosage. Identification of the drug enables you to pay for the services.”

CPT^® is a registered trademark of the American Medical Association.