TMPPM 2008 > Texas Medicaid Services > Physician > Procedures and Services

36.4.20 Injections

Injections are reimbursed as access-based fees under the physician fee schedule in accordance with 1 TAC §355.8085. Texas Medicaid Program fee decisions for blood clotting factors, pneumococcal and hepatitis B, injections, infusion drugs furnished through an item of implanted DME, and new injections are based on 89.5 percent of the average wholesale price (AWP). New injections are those that received approval for marketing by the FDA within the past 12 months.

For certain, specific injections studied by the Office of Inspector General (OIG)/General Accounting Office (GAO), Medicaid fee decisions are based on the recommended percentages of AWP resulting from those studies (Table 1 in §20 of Chapter 17 of the Medicare Claims Processing Manual, Pub. 100-04). For the remaining injections not listed above, fee decisions are based on 106 percent of the average sales price (ASP).

HHSC reserves the option to use other data sources to determine fees for injections when AWP calculations are determined to be unreasonable or insufficient.

Prescriptions are covered under the Texas Medicaid VDP. The reimbursement methodology for pharmacy services is located at 1 TAC §§355.8541 through 355.8551.

Injection administration billed by a provider is reimbursed separately from the medication. Injection administration should be billed using procedure code 1-90772.

Injection administration is not payable to outpatient hospitals. Procedure code 1-90772 is limited to one per day, unless the claim clearly indicates the medications could not be mixed. Procedure code 1-90772 is paid in addition to an E/M or consultation visit to ensure that each injection receives one administration fee regardless of the dosage.

Providers billing injections for clients younger than 21 years of age are to bill using the appropriate national code.

Use oral medication in preference to injectable medication in the office and outpatient hospital unless one of the following applies:

•No acceptable oral equivalent is available.

•Injectable medication is the standard treatment of choice.

•The oral route is contraindicated.

•The patient has a temperature over 102 degrees Fahrenheit (documented on the claim and in the medical record) and a high blood level of antibiotic is needed quickly.

•The patient has demonstrated noncompliance with orally prescribed medication that is documented on the claim and in the medical record.

•Previously attempted oral medication regimens have proved ineffective as supported by the medical record.

•It is an emergency situation.

Injections into joints, bursae, tendon sheaths, or trigger points are only payable for acute conditions or acute flare-ups of chronic conditions. For reimbursement, modifier AT must be used to indicate acute conditions. If a steroid medication is injected in one of the above areas, modifier AT or KX must also be used on the charge for the drug to indicate an acute condition. When performed for a chronic condition, these procedures are denied.

The acute condition does not apply to allergy injections or medically necessary injections into joints, bursae, tendon sheaths, or trigger points when used to treat acute conditions or the acute flare-up of a chronic condition.

Oral medications are not a benefit of the Texas Medicaid Program except when given in the hospital or physician's office, or when obtained by prescription through the VDP. Take-home and self-administered drugs are not a Medicaid benefit except when provided to Medicaid clients through the VDP and should not be submitted to TMHP for payment.

Physicians billing for injectable antibiotic and steroid medications must indicate the appropriate modifier with the appropriate injection code. The code identifying the dose administered must be used for correct reimbursement. Multiples of codes should be billed if a code is not available to document the dose administered (for example, procedure code 1-J0290-use a quantity of 2 for 1,000 mg).

The ET and KX modifiers are acceptable. Use modifier KX to indicate:

•Oral route contraindicated or an acceptable oral equivalent is not available.

•Injectable medication is the accepted treatment of choice. Oral medication regimen has proven ineffective or is not applicable.

•The patient has a temperature over 102 degrees and a high level of antibiotic is needed immediately.

•Injection is medically necessary into joints, bursae, tendon sheaths, or trigger points to treat an acute condition or the acute flare-up of a chronic condition.

The Texas Vaccines for Children (TVFC) Program provides vaccines for Medicaid clients who are younger than 19 years of age, according to the Recommended Childhood Immunization Schedule (Advisory Committee on Immunization Practices [ACIP], American Academy of Pediatrics [AAP], and the American Academy of Family Physicians [AAFP]).

Refer to: "Vendor Drug Program" for more information.

"Immunizations".

"Immunizations" for information on immunizations for infants and children.