Gastroenterology Coding Alert

Many gastroenterologists have added the new drug Remicade (infliximab) to their repertoire of treatment options for patients with Crohns disease (555.9). Because the drug only recently has been approved for use by the federal Food and Drug Administration (FDA), however, there are several coverage issues and coding changes that gastroenterologists using the drug need to be aware of to ensure reimbursement.

Remicade was approved for the treatment of Crohns disease by the FDA. The drug is administered intravenously to patients in a procedure that takes two or more hours to complete. Because of the lengthy time involved, some gastroenterologists may choose to have the drug administered to the patient at a hospital, though it also can be done in an office or outpatient setting.

New HCPCS Code Assigned

Effective Jan. 1, 2000, the drug was assigned HCPCS code J1745 (injection, infliximab, 10 mg). When it first was approved, however, there was no specific HCPCS code for Remicade and code J3490 (unclassified drugs) generally was used on Medicare claims.

Although Remicade has its own HCPCS code now, gastroenterologists should check with their local payers before using it because some may not recognize the new code. While Remicade is covered by most state Medicare payers and the majority of those payers are switching to code J1745, there are still some local payers who prefer to remain with code J3490 or to use a local code, says Michael Ziskind, senior manager of healthcare economics and reimbursement at Centocor, the maker of Remicade. Also it takes time until the computers of all the payers have been updated to recognize the new code.

Gastroenterologists who administer the drug to patients in an office setting also can report codes 90780-90781 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician), according to Ziskind. Code 90780 should be used to report the first hour of intravenous infusion, while 90781 is used to report each additional hour (up to eight hours) of infusion.

Conventional Therapies Have Been Tried and Failed

Because Remicade is a new drug and also is very expensive, most local payers stipulate that the drug can be used only after the patient has failed to respond to other treatment options. The local medical review policy for Ohio states that the patients clinical record must indicate the conventional therapies that have been tried and the patients past responses in an objective manner.

In the case of Crohns disease, those conventional therapies will be other drugs. We turn to Remicade when the patient experiences severe diarrhea or weight loss without a definitive response to steroids, says Donald Vidikan, MD, a gastroenterologist with Rockford Gastroenterology, a practice of nine gastroenterologists in Rockford, Ill. Also if the patient has been on steroids for an extended period of time, perhaps two to three months, and theres been no progress, we will want to look at trying Remicade.

Another coverage stipulation of many carriers is the number of times this treatment may be used, which may not be in line with what the gastroenterologist would prefer to do. The coding guidelines for Remicade in New Jersey, for example, limit the treatment to three infusions performed at zero weeks, two weeks and six weeks for fistulizing Crohns disease. According to Vidikan, however, the response from patients to Remicade will last eight to 16 weeks. After that they have to be infused again, he adds. So far, weve been fortunate to work with insurance companies that have allowed repeated infusions, but that may not be the case with every payer.

Precertify With Commercial Payers

Remicade also has gained wide acceptance among commercial insurance payers in the short time its been on the market, according to Ziskind, who adds, The coding for commercial insurance companies is fairly consistent with what is done for Medicare.

With commercial insurance companies, however, gastroenterologists should determine if precertification is necessary for Remicade. While we arent having problems getting approval for Remicade, we always do it [precertification] because of the expense involved with the treatment, says Peg Hopwood, supervisor of patient accounts for Rockford Gastroenterology. Also, not all insurance companies may be aware of the drug.

Hopwoods process for precertification includes contacting the insurance company and offering to send it a copy of the letter of medical necessity, kept in the patients file. In that letter, the gastroenterologist indicates the signs and symptoms of the patient and conventional treatments that have been tried previously. Hopwood also offers to supply the insurer with a copy of the letter from the FDA that shows the indications approved for the drug.

The insurance companies approval usually takes less than a week, according to Hopwood, and the treatment often is approved on the spot. She is aware, however, that not all gastroenterologists may have such an easy time getting the drug reimbursed.

When we first started using the drug, we had to supply the insurance companies with a lot of information, she explains. Another gastrointestinal practice, especially those in larger metropolitan areas with national carriers, may have to do this for a longer time and have more problems with than weve had."