Gastroenterology Coding Alert

Learn how you can collect for saline infusions as well

Insurance carriers will pay for Remicade infusions for patients with moderate to severe cases of Crohn's disease, but you can't just jot down the J code and drop the bill in the mailbox.

Abide by the following four steps for each of your Remicade infusion claims:

Step 1: Document the Other Therapies Tried

There are several treatment options that could curb Crohn's symptoms before Remicade becomes a reality, such as oral medications containing steroids or mesalamine, dietary changes, and nutritional supplements. Trying other treatments first will also benefit the patient, experts say.
 
Payers will want to see proof that your gastroenterologist has tried other methods before using Remicade. Therefore, you should include documentation of previous therapies attempted, along with the patient's responses to each.

Step 2: Have Patient's Condition Clearly Explained

When reviewing the documentation, payers will consider the patient's condition when deciding whether a Remicade infusion is justified.
  
Hot tip: Most of the time, they will expect that an office has documented each of the following before green-lighting a Remicade payment:
 - severity of abdominal cramping/pain
 - severity/frequency of diarrhea
 - extraintestinal manifestation(s)
 - the presence of any fistula, abscess or mass
 - description of conventional treatments attempted
 - overall patient well-being
 - the results of pretreatment tuberculosis (TB) testing (Note: TB testing is now standard of care, and you can separately code this using 86580, Skin test; tuberculosis, intradermal.)

Red flag: Just because payers may be looking for these details, you should always base your claim on what your gastroenterologist documents.
 
Some offices use the Crohn's Disease Activity Index, a system that objectively measures how a patient is responding to treatment changes. The index takes into account several factors, including frequency of bowel movements, pain, well-being, weight changes, blood counts and other symptoms related to Crohn's disease. A description of how Remicade therapy would improve the condition of the patient may also help the payer decide if an infusion regimen is justified.
 
Step 3: Treat Time as a Vital Factor

Keeping track of exactly how long a Remicade infusion session lasts is also vital to maximum ethical reimbursement. -Physicians will document the start and stop time in the chart,- says Melissa Scolese, revenue management auditor for the DuBois Regional Medical Center in DuBois, Pa.

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, 1 to 8 hours [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. Such services are -bundled- into the infusion time.
 
Step 4: Don't Miss Out on Drug Supplies

If your office supplies the Remicade used during infusion, you may report this separately with J1745 (Injection, infliximab, 10 mg), Scolese says. The physician may also use saline to infuse the pharmaceutical. You can bill for that supply with J7050 (Infusion, normal saline solution, 250 cc) for every 250 cc the physician administers.
 
There's a catch: Not all payers will reimburse for the saline supplies.

Follow This Example

Suppose you provide Remicade infusion in your office for a Medicare patient with Crohn's disease. You infuse a total of 300 milligrams of the drug, along with saline, over a period of 125 minutes.
 
In this case, you should report:
 - 96413 for the first 60 minutes of infusion
 - 96415 for the additional 65 minutes of infusion
 - J1745 x 30 for the Remicade supplies (the drug comes in 100-mg bottles, but you should report use per 10 mg)
 - J7050 x 1 for each 250 mg of saline supply.

Link a diagnosis of 555.9 (Crohn's disease NOS) to 96413-96415.
 
Bonus: If a patient presents with signs and symptoms of volume depletion or dehydration, and the supervising physician determines the patient must be hydrated prior to administering Remicade, you can also report 90760 (Intravenous infusion, hydration; initial, up to 1 hour) for the first 60 minutes of infused hydration and +90761 (... each additional hour [list separately in addition to code for primary procedure]) for each subsequent hour. -We do report saline infusions, and most payers do reimburse for them,- Scolese says.

Be certain to attach the appropriate diagnosis code reflecting the patient's signs/symptoms of volume depletion or dehydration. Otherwise, payers will bundle the saline administration before or after a standard Remicade infusion into 96413 and 96415.
 
Remember: You can only report infusions that take place in the physician's office, not those that occur in a hospital inpatient/outpatient setting.