Pro Fee Drug Reimbursement

Quest ion:

We need some information regarding billing for xylocaine with epinephrine in the physician office setting Specifically, are charges based on units or volume, and can xylocaine w/epi be charged in conjunction with an in-office surgical procedure?

It was our understanding that local anesthetic use is an inherent surgical procedure component, which is not separately billable Are there any circumstances in which it is separately billable in the office setting?

Answ er:

First, there are different reimbursement rules for a freestanding physician clinic than a provider-based clinic/outpatient department of a hospital.

Whether the clinic is freestanding or provider-based, the administration of the local anesthetic is indeed ?integral to?the surgical procedure. The provider should not charge 96372THERAPEUTIC, PROPHYLACTIC, ORDIAGNOSTICINJECTION (SPECIFYSUBSTANCEORDRUG); SUBCUTANEOUSORINTRAMUSCULAR.

A provider-based clinic (reporting facility fees on the UB/837i claim form) can report the pharmacy charge, but lidocaine with epinephrine will be low cost, ergo status N under OPPS. Under OPPS, Medicare and managed Medicare payers will not pay a facility fee for status N drugs, payment is packaged to the other payable lines on the same facility fee claim Pharmacy charges without a HCPCSare reported under rev code 0250 (Of course, a CAH gets paid for every line item that is a covered service, even low cost drugs or supplies, on the CMScost-based reimbursement methodology.)

A freestanding clinic may opt to report a pharmacy charge for the anesthetic drug itself on a separate line of the 837p professional fee claim form. However, it?s not always worth it to go to the trouble. Low cost drugs like lidocaine are more trouble to bill than they?re worth in reimbursement on a professional fee claim

Under MPFS, Medicare pays a professional fee claim 837p for drugs with HCPCSaccording to the rules set forth in Chapter 17 of the Medicare Claims Processing Manual (MCPM)

Attached a PDFdocument which provides the pertinent excerpt from that chapter

Unlike a UB04/837i, a pro fee claim 1500/837p must report a HCPCSor CPT® code on each and every charge line For drugs without a HCPCS, professional fee claims may report the Unclassified Drug HCPCSJ3490, but the claim must indicate the dose and NDCof the drug in the remarks field on the pro fee claim. The MACwill evaluate the note and decide whether/what to pay on that line

Lidocaine is assigned J2001, and epinephrine is J0171 ? and although the combination of the two drugs is available as an SUVinjectable, I didn? t find a HCPCSassigned for the combination medication. You could offer to double-check if CarolinaEast can provide an NDC.

You can find the reimbursement rates under Part B for physician claims for the two HCPCS J2001 and J0171 on the Calculator using the Medicare Part B Drug Payment Allowance report

Neither Lidocaine nor epinephrine are going to yield much in payment:

Bottom line, a lot of drugs are more trouble to bill than they?re worth in reimbursement on a professional fee claim