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Bill injection and drugs separate from procedure

APCs Weekly Monitor, August 11, 2006

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Bill injection and drugs separate from procedure

QUESTION: One of our facilities wanted further information about the recent APCs Weekly Monitor question about packaged drugs. The question is: If a patient comes to the ED for a procedure, for example suturing, and receives an injection for antibiotics, is the injection a packaged service?

ANSWER: In short, no. An injection of an antibiotic is not considered packaged within a laceration suture service. National Correct Coding Initiative (NCCI) guidelines state the following:

Many common activities reflect normal principles of medical/surgical care. These "generic" activities are assumed to be included as acceptable medical/surgical practice and, while they could be performed separately, they should not be considered as such when a code narrative is defined. All services integral to accomplishing a procedure will be considered included.

Some examples of generic services integral to standard medical/surgical services include cleansing, shaving and prepping of skin, local, topical, or regional anesthetic needed to perform the procedure, and dressings. For accurate APC reimbursement, use CPT code 90772 and append modifier -59, which states that the injection is separately identifiable from the laceration repair.

Furthermore, your hospital should also separately bill for the antibiotic drug charge. While there may not be a separate APC payment for the antibiotic, OPPS payment is packaged into the drug administration charge of 90772-59. You should also separately bill the anesthetic drug (which is also likely to be given to the patient). Payment for this drug is likely packaged into the laceration repair code since there is not a separate drug administration code charged for administering the anesthetic.

It is a very important principle of APCs that separately billable supplies and drugs should always be billed separately to ensure correct reporting of resource use to CMS. Note that the pricing of these supplies and drugs are also important: When Medicare applies the hospital cost-to-charge ratios, proper pricing allows it to calculate an amount that closely approximates the actual cost of the supply or drug. This gives CMS the data it needs to make correct decisions regarding whether it should provide separate payment or package the correct amount into the procedure APC for the supply/drug.

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