Written by Norene Anderson
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Injections are subject to many restrictions for reimbursement, especially from Medicare and Medicaid. For instance, therapeutic injections are allowed only if there is not an oral medication that is an effective alternative. Documentation of medical necessity is required to forego these guidelines.

Injections such as Vitamin B-12 are reimbursed only if given for malabsorption syndrome and pernicious anemia. Many injectables have a limit of frequency. Steroid injections are allowed once a month for conditions such as arthritis. Injections of antibiotics are limited to three times if given on three consecutive days.

Complicated Billing of Injections

The coding for injectable drugs is based on the HCPCS system. The Level II injectables are alphanumeric codes used for Medicare and Medicaid. The Level III injectable codes are used when no Level II codes are designated. Level III codes begin with the letters A, C, Q, or S. Many states are cross-walking all of the local x-codes to relevant CPT or HCPCS codes.

A typical example of reimbursement for injectable drugs is the lower of submitted charges, acquisition cost, or AWP (Average Wholesale Price) minus 11 percent. The low reimbursement rate is an issue for many physicians and healthcare providers. It is an ongoing dilemma that healthcare providers, insurance carriers, and the government are working diligently to reach some kind of acceptable balance between cost, profit, and patient care.

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