Section 418.10902. Billing for injectable medications, other than vaccines and toxoids, in office setting.

(1) The provider shall not bill the carrier for administration of therapeutic injections when billing an evaluation and management procedure code. If an evaluation and management procedure code is not listed, then the appropriate medication administration procedure code may be billed.

(2)    The medication being administered shall be billed with either the unlisted drug and supply code from the CPT code set or the specific J-code procedure from Medicare's National Level II Codes as adopted by reference in R 418.10107.

(3)   The provider shall list the NDC number for the medication in the upper shaded portion of box 24 of the CMS 1500.

(4)    The carrier shall reimburse the medication at average wholesale price (AWP) minus 10%, as determined by Red Book or Medi-Span, as adopted by reference in R 418.10107. No dispense fee shall be billed for injectable medications administered in the office setting.

(5)   If the provider does not list the national drug code for the medication, the carrier shall reimburse the medication using the least costly NDC number by Red Book or Medi-Span for that medication.

History: 2003 AACS; 2005 AACS; 2007 AACS; 2008 AACS; 2014 AACS.