Gastroenterology Coding Alert

If the physician supervises a nurse practitioner, the same codes apply. "A registered nurse infuses each patient, checks vitals routinely throughout the infusion and is in constant attendance for the duration of the infusion," Ingoldsby says. "A physician must be present within the suite for a patient to receive an infusion. Although the registered nurse is infusing, he or she is working under the supervision of a medical doctor."

When the nursing staff independently provides the infusion, bill a nurse visit (99211). The nurse code applies to established patients only. "If the doctor hasn't first seen the patient, you can't bill 99211," says Mary Anne Burke, billing manager, Gastroenterology and Internal Medicine Group in Hartford, Conn. Do not report 99211 in addition to 90780. "The first hour [of intravenous infusion] includes the nurse's time, the monitoring and other services. Chances are insurers may pay 99211 rather than 90780."

However, a patient who comes in for an infusion and has a different problem warrants a separate E/M, she says. Ingoldsby adds that her doctors would perform both procedures "as long as the problem did not present itself as a contraindication for the infusion." To indicate that the service was separate and unrelated to the infusion, you must append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

If the physician performs an E/M service related to the Crohn's disease and documents the E/M service, you should also bill for the E/M service at the level appropriate to the problem and documentation (99212-99215, Office or other outpatient visit ...). In addition to Crohn's related symptoms (abdominal pain, joint pain, skin rash, etc.), the patient may have problems with side effects of medications (hypertension, diabetes, etc.). It would still be reasonable in most cases to proceed with the infusion.

LMRPs break ICD-9 requirements into two categories of Crohn's disease, active and fistulizing.

Acceptable diagnoses that prove medical necessity of IV treatment for active Crohn's disease include:

For fistulizing Crohn's disease, LMRPs, including Nationwide Medicare (Part B carrier for Ohio and West Virginia), Empire Medicare Services (Part B, New Jersey) and Blue Cross/Blue Shield for Alabama, allow:

Claims submitted with 565.1 and 569.81 must list the fistulizing diagnosis first and the active diagnosis second. Cigna and Nationwide deny the service "if both the primary and secondary diagnosis codes are not indicated on the claim." "Medicare had a problem understanding that for fistula more than one infusion wasn't repetitious," Burke recalls. The regional enteritis diagnoses "substantiate the patient has fistula."

Treatment for moderate to severe Crohn's disease calls for a single infusion of 5 mg per kg over at least two hours. For patients with poor responses to the initial 5 mg/kg infusion, gastroenterologists are using higher dosages (up to 10 mg/kg). Payers require various notation on the HCFA 1500 claim form to indicate the initial infusion. Cigna and Georgia Medicare Part B require the free form line to read "first dose." Nationwide mandates "initial infusion." When using 555.0-555.9 for a patient who relapses, the payer stipulates recording "relapsed." Carriers limit repeat infusions from no more than one every six weeks to a maximum of three in six months.

Fistulizing Crohn's disease calls for three infusions scheduled at weeks zero, two and six. The same 5 mg/kg dosage is administered at each session. For the first therapy, record on the claim form "1 of 3 doses." Indicate the second treatment with "2 of 3 doses" and so on.

Payers cover infusion for moderate to severe Crohn's disease for patients who do not adequately respond to conventional treatment. Documentation should reflect tried therapies and the patient's response.

Both types of Crohn's disease require thorough documentation of all related signs and symptoms, such as presence and severity of abdominal pain, extraintestinal manifestation, control of diarrhea, the site and number of draining fistulas. Explaining the patient's level of wellbeing and how the therapy can improve it may also help substantiate medical necessity.

Some carriers, such as Blue Cross/Blue Shield of Alabama, provide predetermination forms for initial, staged and relapse therapy. Blue Cross/Blue Shield Regence also stipulates that for covered infusion treatment for active Crohn's disease the patient must be experiencing a disease flare and demonstrate ineffectiveness or intolerance to various drugs.

If the gastroenterologist administers Remicade in the office, you should report the supply J1745 (Injection, infliximab, 10 mg) in block 24-D of the HCFA claim form. Remicade is sold in 100-mg vials. Bill by the unit, not the vial. If the patient weighs 132 lbs (60 kg), the usual treatment would be 300 mg. You should assign J1745 with a "30" in the units field. If a vial is only partially used, most carriers allow the entire vial to be reimbursed, and some "wastage" is expected.

"Putting the national drug code for Remicade (57894003001) in the description column helps the insurer target which drug was used," Burke says. She also records "Remicade 100-mg use."

For subsequent infusions, Cigna and Empire require appending modifier -EJ (Subsequent claims for a defined course of treatment) to the supply code.

You should also charge for the saline solution with J7050 (Infusion, normal saline solution, 250 cc).