Gastroenterology Coding Alert

Medicare may also do away with G codes

Editorial changes and a series of new codes mean you-ll no longer report 90780-90781 for in-office Remicade infusions for non-Medicare patients. Instead, you should look to newly added -chemotherapy administration- codes 96413-96417.

Treat Remicade as a Biologic Response Modifier

This year, you needn't limit -chemotherapy administration- codes to patients with a cancer diagnosis. Instead, you will apply such codes -based upon the inherent risk of the agent administration- and -management of the possible toxic effects of the drug, rather then upon the cancer diagnosis most commonly associated with chemotherapy treatment,- according to AMA's CPT Changes 2006: An Insider's View. Agents that fall into this category include -monoclonal antibody agents and other biologic response modifiers---of which Remicade is an example, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

In short: Although Remicade is not a chemotherapy drug, CPT instructs you to report Remicade administration using chemotherapy infusion codes.

Specifically, you will report in-office Remicade infusion (for treatment of Crohn's disease) using two new codes:

- 96413--Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

- + 96415--... each additional hour, 1 to 8 hours (list separately in addition to code for primary procedure).

Pay Attention to Time

As in years past, you must keep track of exactly how long a Remicade infusion session lasts. For the first hour of infusion, you should report 96413. Use add-on code 96415 for each subsequent hour, Parks says.

Example: A patient with Crohn's in an unspecified site reports to the office for Remicade infusion. The gastroenterologist infuses 300 milligrams of the drug over a two-hour period. On a claim for a private payer, you would:

- report 96413 for the first hour of infusion
- claim add-on code 96415 for the second hour of infusion
- link a diagnosis of 555.9 (Crohn's disease NOS) to 96413/96415 to prove medical necessity for the infusion.

The time you report -should be based only upon the administration time for the infusion,- according to CPT Changes. In other words, services leading up to the infusion and to conclude the infusion (for example, starting the IV and monitoring the patient postinfusion) are -bundled- to the infusion time. You cannot report these services separately or count them toward the infusion time.

Watch your site of service: Remember, you can only report infusions that take place in the physician's office, not those that occur in a hospital inpatient/outpatient setting.

For Medicare, Stick With G Codes--for Now

In 2005, Medicare payers instructed providers to use G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) and G0360 (Each additional hour, one to eight [8] hours [list separately in addition to code for primary procedure]) for Remicade infusion, says Matthew Lautzenheiser, senior administrative manager at Johns Hopkins Medicine in Baltimore.

Codes 96413/96415 share nearly identical descriptors with these G codes, but until CMS says otherwise, you should continue to report G0359/G0360 for Medicare.

Example: In a case identical to that described above, the gastroenterologist provides a 300-milligram Remicade infusion for a Medicare patient over two hours. You would report:

- G0359 for the first hour of infusion
- G0360 for the second hour of infusion
- a diagnosis of 555.9.

Keep watching: Many coders and clinicians do expect Medicare to adopt the new CPT codes for Remicade, says Mary Brown, CPC, director of client services at Partners in Practice in Sarasota, Fla. Keep watching Gastroenterology Coding Alert for information.

Don't Forget Supplies

In addition to the infusion service, you should report the drug supplies the physician administers. The appropriate supply code for Remicade is J1745 (Injection, infliximab, 10 mg).

For instance: In each of the two examples above, the physician infused 300 mg of Remicade. Therefore, in each of the above examples, you should also report J1745 x 30 for the drug supply.

Possible snag: You should check with your local payers before using J1745. Some may prefer a local code for Remicade or J3490 (Unclassified drugs).

With Remicade infusions, the physician will typically use saline to infuse the pharmaceutical. You can bill for that supply, using J7050 (Infusion, normal saline solution, 250 cc) for every 250 cc the physician administers, Lautzenheiser says.