§ 9789.13.2 Physician-Administered Drugs, Biologicals, Vaccines, Blood Products

Summary

For medical services rendered on and after January 1st, 2014, the RBRVU Physician Services Fee Schedule consists of 48 Regulations, including 40 fee-affecting regulations. Knowing and understanding these additional fee-affecting regulations is critical to determining the correct reimbursement for services.

The regulation determining reimbursement for physician administered drugs, biologicals and blood products is one of the most complicated regulations.

Physician-administered drugs, biologicals, vaccines, or blood products are separately payable.

  • For vaccines this regulation clearly states that both the vaccine service and the vaccine drug are reimbursable. The regulation instructs billing both the vaccine procedure code and the NDC for the vaccine product.
  • For other physician-administered drugs, both the drug administratration service and the drug products are reimbursable. The regulation instructs billing both the procedure code for the service and the J code for the drug product.
  • If a J code does not exist for the drug product, the regulation instructs billing the drug product using the NDC number associated with the drug product.

Physician-Administered Drugs, Biologicals, Vaccines, Blood Products: Table

Medi-Cal Rates File

Per section 9789.13.2, the California Medi-Cal Rates file determines the reimbursement for J-codes. The Physician Fee Schedule adopts a new Medi-Cal file on the 15th of every month.

Medi-Cal Rates File; Physician services Fee Schedule

Medi-Cal Rates File:

Medi-Cal Rates File; Physician services Fee Schedule

How do I bill for chemotherapy injections and radiopharmaceuticals?

Section 9789.13.2 explains the regulations for physician-administered drugs, biologicals, vaccines, or blood products. All physician-administered drugs, biologicals, vaccines, or blood products are separately payable, including cancer chemotherapy injection.

Physician-administered radiopharmaceuticals, components for specific procedures (listed below) are separately payable when the TC is payable.

For more information, refer to the regulation linked below.

California Code of Regulations (CCR)

§ 9789.13.2 Physician-Dispensed Drugs

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

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