How do I bill for physician-administered pharmaceuticals?

ANSWER: The regulation determining reimbursements for physician-administered drugs, biologicals and blood products is extremely complex and difficult to follow.

The physician fee schedule distinguishes vaccines from other drugs, biological, and blood products. For vaccines, regulation 9789.13.2 determines that both components are reimbursable:

  • the vaccine service, and
  • the vaccine drug.

The regulation also states that “vaccines shall be reported using the NDC and CPT-codes.” This means billing CPT code 99070 along with the NDC number for the vaccine product.

Reimbursements for Physician-Administered Vaccines

For other physician-administered drugs, including physician-administered biological & blood products that are not vaccines, regulation 9789.13.2 determines that both components are reimbursable:

  • the drug administration service, and
  • the drug product.

The regulation instructs billing both the procedure code for the service and the J code for the drug product.

Other Physician-Administered Products: J-Code + NDC Number

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.

The codes for most drug products are in the Medi-Cal Rates file. If a J code does not exist for the drug product, the regulation instructs billing the drug product using only the NDC number associated with the drug product, without the J code.

Medi-Cal Rates File; Physician services Fee Schedule

Medi-Cal Rates File:

Medi-Cal Rates File; Physician Services Fee Schedule

NOTE: The amount in the Medi-Cal Rates file spreadsheet is NOT the final reimbursement amount. For workers’ comp billing, the injection administration fee of $4.46 must be subtracted from the amount in the Medi-Cal Rates file.

California Code of Regulations (CCR)

§ 9789.13.2 Physician-Dispensed Drugs

Division of Workers’ Compensation Websites

Official Medical Fee Schedule

DaisyBill Resources

Technology is your friend when it comes to calculating correct fee schedule reimbursements. DaisyBill’s OMFS Calculator makes determining accurate reimbursements quick and hassle-free for current AND past dates of service.

Sign up for a free trial of the DaisyBill OMFS Calculator and instantly start calculating easier.

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