Gastroenterology Coding Alert

Question: A patient came in to our office for a Remicade infusion to treat her Crohn's disease, but also underwent a hydration procedure because she exhibited symptoms of volume depletion. How should I code for this encounter?

Nevada Subscriber

Answer: In this situation, you should report the hydration in addition to the Remicade infusion, which you would report with chemotherapy administration codes. For the hydration, you would report 96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code forprimary procedure]). For the Remicade infusion, you would report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour and 96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]) for each additional hour.

Don't miss: You would also append modifier 59 (Distinct procedure service) since the Correct Coding Initiative bundles hydration into the Remicade infusion, unless the physician documentation indicates hypovolemia (dehydration). You should use 276.51 (Dehydration) as the diagnosis code for this procedure.