A. General

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 the 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 the 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.