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. [...]