Health Information Management

Billing scenarios for daily outpatient antibiotics

APCs Insider, May 14, 2004

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QUESTION: Will Medicare cover a discharged patient who needs daily antibiotics for Methicillin Resistant Staph (MRSA) on an outpatient basis? How should the hospital charge for this service?
 

ANSWER: First, it is not clear whether the antibiotics were self-administered, injected, or infused. If self-administered, then outpatient hospital services would not be medically necessary unless your hospital has a provider-based physician clinic that is medically managing the patient for MRSA. In this case, you would bill an E/M visit.

If injected, the treating physician would have to order the injection from the hospital, as opposed to performing it in his or her own clinic/office. In this case, the injection code 90788 and the drug would be billable. An E/M would not be billed unless there was a separately identifiable service performed, such as an assessment for fever.

If the medication was infused, the treating physician would have to order infusion from the hospital. If it was an ambulatory infusion from a pump taken home, then the treating physician would order ambulatory infusion from a DME company and order IV site care/pump maintenance from either the hospital or a home-health agency. In this case, pump maintenance is CPT 96520. The durable medical equipment (DME) company would bill the drug and pump and supplies separately as they are delivered to the patient's home.

If the medication was the infusion must be medically monitored, the hospital would bill Q0081 and for the drugs infused. An E/M would not be billed unless there was a separately identifiable service performed during the visit, such as an assessment for fever. We believe these to be all the possible scenarios for daily antibiotics on an outpatient basis.



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