September 20, 2018

Question:
There is a lot of confusion in our office when the doctor injects viscosupplementation and it is not covered by a plan. The physicians want to report 20610 to the payor for the injection and have the patient self pay for the drug.  Our billers do not believe this practice is correct. They believe the entire service should be self pay, drug and injection.  If you agree with the billers, is there anything in writing we can use to convince our surgeons that they should not be billing the payor for the injection?

Answer:
This is a question that is asked often by clients, so we understand there is a lot of confusion out there.  We agree with the billers. When the payor indicates that a drug is experimental or not considered “reasonable and necessary” and therefore is not covered, why would one think it OK to bill the mode of administration of the uncovered drug?  There is documentation to support this line of thinking in the Medicare Carrier Manual.

50.4.3 Examples of Not Reasonable and Necessary

“If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the A/B MAC (B) or DME MAC excludes the entire charge (i.e., for both the drug and its administration). Also, A/B MACs (B) exclude from payment any charges for other services (such as office visits) which were primarily for the purpose of administering a noncovered injection (i.e., an injection that is not reasonable and necessary for the diagnosis or treatment of an illness or injury).”

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

*This response is based on the best information available as of 09/20/18.