Typical Co payments for Epidural Pain Medication/Shots

[timeflies]

One of my MAPD members recently contacted me. He had an office visit with a Pain Specialist. The doctor, or his nurse I believe, gave him a shot to help ease the pain. Not sure if these are always Epidural shots or not but I know a lot of seniors on Medicare plans see their pain specialist for this type of "shot" every month. This member was billed $295 for the shot as it was coded as an Outpatient procedure by the doctor's office. I called his MAPD plan, Anthem, and I was told that the if there was a concern about the bill being coded properly, he had to work with the providers billing service and not Anthem. I informed the member of what I was told so he called the providers office back and he was told that the proper billing codes were used for the procedure. It doesn't make sense to me that getting a shot like this in the doctor's office and not at a ambulatory surgical center or a hospital would be consider a "procedure" Can anyone enlighten me if the shot was billed properly? I have "googled" this several times, but I cannot seem to find a clear answer to this question.

 

[somarco]

Of course the administration of medication is a procedure. You are asking the wrong question. There is no such thing as a "typical" copay especially with MA plans.

What you want to know is the ICD-10 code

2018 ICD-10-PCS Codes 3E0S*: Epidural Space
Coding for Epidural Steroid Injections - Career Step Blog
Coding, Classification and Reimbursement - American Health Information Management Association

This data (below) is dated but might offer a clue on the Medicare allowable
http://www.mowles.com/Billing Facility Fees.pdf

This is more current
https://www.halyardhealth.com/media/272239/2016-Medicare-Payment-Rates-for-PMP-Procedures.pdf

Unless your question was extremely general, I am surprised Anthem would tell you anything. Specifics about a policyholder claim is a HIPAA violation.

 

[timeflies]

Thanks. Is administration of the flu vaccine considered a procedure? I know its considered preventative and the plans usually pay the full cost of the flu shot. I tried to look up some other billing codes but quickly got lost. Is there a good resource available other than going to 3-4 sources to easily find this kind of information, or not? I am assuming there is not one central source of info since you included several sources for your reply.

 

[somarco]

Things you do yourself . . . take pills, self injection, use an Ace bandage, etc. . . . is NOT considered a procedure.

If a medical provider does it for you or to you, that's a procedure.

There are plenty of sites with ICD-10 and CPT-4 codes but most are highly technical and normally only used by medical personnel. Most require a subscription.

If @WCMason was still active on this site I am sure he would offer some valuable insight into your question. Unfortunately for most of us, he has all but abandoned the forum because of one very selfish individual.

 

[timeflies]

Thanks again.

 

[policywunk]

One of my MAPD members recently contacted me. He had an office visit with a Pain Specialist. The doctor, or his nurse I believe, gave him a shot to help ease the pain. Not sure if these are always Epidural shots or not but I know a lot of seniors on Medicare plans see their pain specialist for this type of "shot" every month. This member was billed $295 for the shot as it was coded as an Outpatient procedure by the doctor's office. I called his MAPD plan, Anthem, and I was told that the if there was a concern about the bill being coded properly, he had to work with the providers billing service and not Anthem. I informed the member of what I was told so he called the providers office back and he was told that the proper billing codes were used for the procedure. It doesn't make sense to me that getting a shot like this in the doctor's office and not at a ambulatory surgical center or a hospital would be consider a "procedure" Can anyone enlighten me if the shot was billed properly? I have "googled" this several times, but I cannot seem to find a clear answer to this question.

This is an issue with MA plans that have a high fixed co payment for OP services instead of 20% co insurance or at least a tiered co pay for OP in doctors office,OP center or hospital OP center- obliviously on the Anthem Plan the provider can bill the 295.00 no matter what OP service it is or where its done- not good. Interestingly I see some dermatologist and pain specialist bill separate for minor OP procedures in their office while other only charge for the 35.00 office visit for the same procedure on the same plan so I guess greed plays in to it too.