Gastroenterology Coding Alert

Question: How should I code this encounter: An established patient with a plan of care in place for his Crohn's disease of the ileum presents to the office for a Remicade infusion. The gastroenterologist began the infusion at 10:00 a.m. and finished at 11:42. The patient reported nausea during the infusion, so the gastroenterologist administered 200 mg of Benadryl from 10:41 to 10:52?

Vermont Subscriber

Answer: Your claim should be divided in two parts:

Remicade infusion, which lasted for one hour and 42 minutes. Report the following codes:

• 96413 -- Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour
• +96415 -- ... each additional hour [List separately in addition to code for primary procedure]) for the remaining 42 minutes
• 555.0 -- Regional enteritis; small intestine) linked to 96413 and +96415 to represent the patient's condition
• J1745 -- Injection, infliximab, 10 mg) x 20 for the supply of Remicade

Benadryl infusion, which took less than 15 minutes. This time is very short, but you could possibly push it by reporting:

• +96375 -- 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] 555.0
• J1200 -- Injection, diphenhydramine HCl, up to 50 mg (for the Benadryl supply).