Gastroenterology Coding Alert

The bottom line is this -- you won't get paid for Remicade services unless you have a handle on drug-therapy coding.

Follow these expert tips to determine which codes to report for Remicade as well as other drug administrations, and you'll reap the reimbursement benefit.

You know that when you report Remicade infusions, you must include a diagnosis code, but do you know how to ramp up your specificity? Our experts show you how.

Important: You should always report based on your physician's documentation, not based on what carriers will pay. However, you should be aware of what you will commonly see for Remicade infusions. For instance, you will likely see the following diagnoses among your carrier's approved list:

• 555.0-555.9 -- Regional enteritis (Crohn's)

• 556.0-556.9 -- Ulcerative colitis

• 565.1 -- Anal fistula

• 569.81 -- Fistula of intestine, excluding rectum and anus

• 696.0 -- Psoriatic arthropathy (which you will report with 720.81, Inflammatory

spondylopathies in diseases classified elsewhere)

• 714.0 -- Rheumatoid arthritis

• 720.0 -- Ankylosing spondylitis.

"Code 555.9 is the one I see 98 percent of the time," says Joyce Carpenter, CPC, OGS, MCMC, billing department lead of Internal Medicine Associates in Anchorage, Alaska. "But if you can get a more specific code than 555.9, then by all means use it."

Example: Don't forget that you can expand on the patient's story by adding a secondary diagnosis, such as ankylosing spondylitis (720.0), Carpenter adds.

Keeping track of exactly how long a Remicade infusion session lasts is also vital to maximum ethical reimbursement. Physicians should document the start and stop time in the chart.
If your physician infuses a Crohn's patient with Remicade, use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour. Use add-on code +96415 (... each additional hour [list separately in addition to code for primary procedure]) for every subsequent hour.

- Remember: Although 96413 and 96415 specify "chemotherapy administration," the codes also apply to infusions of "monoclonal antibody agents and other biologic response modifiers" -- and Remicade falls into this category, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.

- Good idea: Also, when reporting 96413 and 96415, remember to track the time "based only upon the administration time for the infusion," according to the AMA's CPT Changes 2006: An Insider's View. Therefore, you cannot count time spent starting the IV and monitoring the patient post-infusion, for example. Most carriers bundle these services into the infusion time.

Example: The patient undergoes a three-hour Remicade infusion and takes an oral Benadryl upon arrival. For this, you'll report one unit of 96413 to represent the first hour and two units of 96415 to represent the two following hours. You'll also report the supply using J1745 (Injection, infliximab, 10 mg), depending on the amount of dosage (which you'll calculate based on every 10 mg). "We include our oral Benadryl as a given," Carpenter adds.

Note: If you provide Benadryl through an IV, you'll likely add J1200 (Benadryl, up to 50 mg).

The patient's Remicade infusion may also include other services, such as hydrations and other medicine infusions. In these situations, you should report these codes as well.

Example 1: The patient presents for a three-hour Remicade infusion but also goes undergoes a one-and-a-half- hour hydration, because she demonstrates symptoms of volume depletion. The total time was four-and-a-half hours.

In this situation, you'll report 96413 for the first hour of Remicade infusion. Then, you'll include two units of 96415 for the additional two hours.

For the hydration, you'll report +90761-59 (Intravenous infusion, hydration; each additional hour [list separately in addition to code for primary procedure]; distinct procedural service). You have to include modifier 59, because the Correct Coding Initiative (CCI) bundles hydration into the Remicade infusion, unless your physician's documentation demonstrates hypovolemia or dehydration. That means you have to include a diagnosis of hypovolemia (276.52) to link to 90761.

Don't forget to include J1745 for each 10 mg of Remicade dosage.

Example 2: The patient presents for a Remicade infusion plus an IV Benadryl 50 mg prior to infusion. The total infusion time is two hours 20 minutes.

You'll report one unit of 96413 and one unit of 96415.

Note: You have to have at least 31 minutes to pick up the additional hour.

Then, you'll add +90775 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [list separately in addition to code for primary procedure]) for the Benadryl IV. "You'll often use this code with Remicade infusion code 96413," Carpenter says.

For the supplies, report J1200 and J1745 for each 10 mg of Remicade dosage.

Example 3: The patient presents for a two-hour- 45-minute Remicade infusion plus a 45-minute SoluMedrol infusion.

You should report one unit of 96413 for the first hour of Remicade infusion, and include two units of 96415 for the additional two hours.

Then, report +90767 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion, up to one hour [list separately in addition to code for primary procedure]) for the SoluMedrol infusion.

Be sure to include J1745 for each 10 mg of Remicade dosage and J2930 (Injection, methylprednisolone sodium succinate, up to 125 mg) for the SoluMedrol.

You should also keep in mind these guidelines.

1. To bill for the infusion of Remicade in the physician office, your gastroenterologist has to be on-site and in the office suite when the patient undergoes the infusion.

2. Medicare does not approve an ambulatory surgical center (ASC) as an acceptable place for infusion therapy.

3. Check with your individual insurance providers to obtain their infusion rules and regulations.