HI 00401.335 Reasonable Charge Screens for Injections
Where a separate charge for an injection is submitted by a physician, and it is the prevailing practice in the community to make such an additional charge, the maximum allowable charge may not normally exceed the approximate ingredient and supply cost plus a $2 allowance for the injection service. Reasonable charge screens for injections, are therefore based on: a flat $2 amount for the service of the physician (or his office nurse) in providing the injection; plus the current cost of the most frequently administered dosage of the drug, as reflected in sources such as Drug Topics Red Book or the Blue Book, (the latest editions), and the cost of supplies such as syringes and needles. (The price of the smallest unit of packaging offered by the manufacturer that will include the most frequently administered dosage of the drug are used in this regard.) However, in cases involving unusual circumstances, an additional allowance above the $2 amount for the physician services may be considered provided proper documentation is supplied. Also, where the claim is documented to indicate that the dosage administered and cost of the drug used were higher than the drug cost that would be applicable to the most frequently administered dosage, the higher drug cost may be allowed to the extent that it is reasonable.
Where an injection is given the patient during an office visit, and the prevailing practice in the locality is not to make a separate or increased charge for injections in such situations, but to charge only the regular office visit fee, the reasonable charge does not include an additional allowance for the injection. Similarly, where an individual physician has not customarily made separate charges for injections in addition to his office visit fee during the year from which the customary charge screen has been derived, the reasonable charge does not include an additional allowance for an injection. In addition, where the carrier knows that the sole purpose of e.g., an “office visit” was for the patient to receive an injection, payment may be made only for the injection (if it is covered). Allowance of a separate additional charge for an “office visit” is not warranted where the services rendered did not really constitute a regular office visit.
All injection claims submitted to a carrier must include the specific name of the drug used. Identification of the drug enables the carrier to correctly pay for the services rendered and helps establish meaningful injection screens.
B. Use of a tolerance
Where the total charge made for an injection (i.e., for the service of the physician and/or his office nurse in providing the injection, and for the cost of the drug and supplies used) does not exceed $3, the actual charge made is determined to be a reasonable actual charge made is determined to be a reasonable charge without any further determination of the drug cost through use of e.g., the Drug Topics Red Book or the Blue Book. Thus, where the actual cost of the drug used was less than $1, use of the $3 tolerance allows room for some cushioning to offset losses due to spoilage and spillage. However, in no case may the reasonable charge exceed the actual charge made for an injection.
C. Injections calling for special skills
Injections such as those that require the precise placement of a needle into inflamed, painful, or target areas or the injection of dangerous drugs may require that only a physician provide this service. Consequently, injections of this nature are not considered routine and appropriate allowances are made. In these instances, the carrier may establish customary and prevailing charge screens to reflect the actual practice of physicians in a locality.