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Gastroenterology Coding Alert

Want Remicade Reimbursement? Prove Medical Necessity, Watch the Clock

Published on Thu Jan 01, 2004

Don't trip when billing infusions

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 three rules of thumb for each of your Remicade infusion claims:

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, says Lois Curtis, CPC, of Gastroenterology Associates in Evansville, Ind.
 
Remicade is "a good treatment, but due to the fact that it's so costly, our doctors try to work with patients to see what treatment is most effective for them," Curtis says.
 
Payers will want to see proof that your gastroenterologist has tried other methods before using Remicade. It would be wise to include documentation of previous therapies attempted, along with the patient's responses to each of them.

2. Document the Patient's Condition

When reviewing the documentation, payers will consider the patient's condition when deciding whether Remicade infusion was justified.
 
According to Delia Bartolotto-Stewart, CPC, of Digestive Health Physicians in Fort Myers, Fla., insurance carriers are particularly interested in the patient's condition. 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
     
  •  description of conventional treatments attempted
     
  •  overall patient well-being.

    Some offices use the Crohn's Disease Activity Index, a system of measurement that objectively measures how a patient is responding to treatment changes. The index takes into account a number of 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 carrier decide if an infusion regimen is justified.
     
    When billing for Remicade infusions, some gastroenterology offices have gone as far as having a form letter on hand addressing all of the above elements, which they complete and send out along with the bill for the first Remicade injection. Consider creating one of these form letters to be sure you have the proper documentation for your next Remicade-injection claim.

    3. Treat Time as a Vital Factor

    Keeping track of exactly how long a Remicade infusion session lasts is also vital to maximum reimbursement. If your physician injects Remicade in a Crohn's patient, use the infusion code 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the first hour. Use add-on code +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) for every subsequent hour.
     
    The same code (90780) applies if the doctor is directing a nurse practitioner during a Remicade infusion. If, however, the nurse practitioner is administering the Remicade without supervision, report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...). Be sure to report this in place of, not in addition to, 90780 - the initial 60 minutes of infusion time accounts for the nurse's time, monitoring and other services.
     
    Also remember that reporting a nurse visit is only possible for Remicade infusions given to established patients.
     
    In 2000, Remicade was given the HCPCS code J1745 (Injection, infliximab, 10 mg). However, gastroenterology offices should still check with their local payers before using the code to make sure the payer recognizes it. Some may prefer a local code for Remicade, or J3490 (Unclassified drugs). Coders can also report the saline solution separately with J7050 (Infusion, normal saline solution, 250 cc).

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