Reimbursement Advisor

RhoGAM injections: payment levels vary among insurers


Q Physicians often send their patients to our hospital for RhoGAM shots. Why is this happening, and what is the best way to code for this service?

A First, many Ob/Gyns opt not to perform RhoGAM injections in their offices because of exceedingly poor reimbursement from third-party payers. Second, there was a shortage of the product in 1995 and early 1996. In many cases, RhoGAM was available only through local hospitals, so a shift in the site of service took place.

To bill for the injection, select 1 of the following codes: 90384 (Rho[D], IM full dose), 90385 (Rho[D], IM mini-dose), and 90386 (Rho[D], IV use). For example, if a full dose of RhoGAM is administered intra-muscularly to a non-Medicare patient, report codes 90384 and 90782 (therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Some payers will require that you submit the HCPCS level 2 code J2790 (injection, Rho[D] immune globulin, human, one dose package) instead, so always check with the insurer before billing.

To facilitate fair payment, submit the National Drug Code number for the drug and the invoice.

While the coding is standard, reimbursement levels vary from payer to payer. Private payers set their rates for covered drugs based on either reasonable and customary charges, or drug wholesale prices. Many Medicaid and managed care companies, however, set their limits below the market value of the drug. If you believe the payment is unfair, appeal the claim and negotiate with the payer for fair market reimbursement.

To facilitate fair payment, submit both the National Drug Code (NDC) number for the drug, which is located on the package insert and identifies the drug name, manufacturer, and dosage, and the invoice that shows the acquisition cost. (NDC numbers are likely to become the sole method of billing for drugs as a result of HIPPA legislation, which includes a uniform code set, that will be implemented on October 1, 2002.)

This article was written by Melanie Witt, RN, CPC, MA, former program manager in the Department of Coding and Nomenclature at ACOG. She is now an independent coding and documentation consultant. Her comments reflect the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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