Health Information Management

Injections covered if medically necessary

APCs Insider, October 22, 2004

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Injections covered if medically necessary

Question: Does Medicare pay for injections administered to patients in the recovery room after a catheter procedure (such as injections of meperidine and promethazine) if billed with administration code of 90784 along with the J code for that injection? Do we report the administration and injection code under revenue code -710 (recovery room), or -481 (cardiac cath lab)?

Answer: Medicare covers injection administrations that are medically necessary.  This means that the injection is not prophylactic or routinely given as part of the procedure. For example, if an antibiotic injection is given routinely to all patients, then the injection administration code is not billable (note that the drug is still billable), regardless of the location of the patient when the injection is given.<P>

However, if an antibiotic is given when a patient exhibits certain clinical signs that meet medical necessity, then the injection administration and drug are both billable. (Fiscal Intermediary Riverbend has taken a much more conservative stand, indicating that they will only pay for one injection fee per date of service). Note that medical necessity must be documented in the record.

J codes are not required for drugs that do not have separate APC payments. Drugs without separate APC payments may be billed under revenue code -250 without a J code, or using -636 with a J code.  Drugs with separate APC payments must be billed under revenue code -636 with their J code in the correct units of service to match the dosage administered and the J code dose definition.
In regard to the best revenue code for the injection administration for recovery room or cath lab when medical necessity is met, this depends on the set-up in the hospital system or requirement by your local FI.  For example, most recovery room charges, such as recovery room time, are reported under revenue code -710 with no HCPCS. Other recovery charges, such as extended recovery time on the nursing floors, may be reported under revenue code- 719 with no HCPCS.

Most systems don't accommodate a revenue code that summarizes time-based charges with no HCPCS while detailing charges with a HCPCS. In this case, revenue code -940 may be a good alternative to the therapeutic service of a medically necessary injection in the recovery room.  

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