Medicare Compliance & Reimbursement

Carriers remove coverage for Natrecor in office setting.

Physician offices running congestive heart failure clinics and providing infusions of Natrecor (Nesiritide) should keep an eye on upcoming carrier bulletins.

Some carriers have already declared that they won't reimburse J2324 (Injection, nesiritide, 0.5mg) in the office setting, because clinical trials only addressed the treatment's effectiveness in the inpatient setting. These carriers include Cahaba GBA as well as Palmetto GBA, which was paying for Natrecor on a case-by-case basis until recently.

"Since these patients need to be closely monitored for response to and side effects of treatment, the medical literature currently does not support the administration of this medication in an office setting," Palmetto wrote in June. Cahaba noted that most clinical trials for Natrecor involved continuous intravenous infusion for 24 to 72 hours in a hospital setting with central hemodynamic monitoring.

"It's got the potential for some very serious side effects, so I guess it's not surprising that they'd want to see it in hospitals only," says consultant Jackie Miller with Coding Strategies in Powder Springs, GA.

The Cardiovascular Group in Lawrenceville, GA had between 15 and 20 patients on Natrecor when Cahaba's announcement came out in March. "Medicare just slammed them," says Connie Cofer, a coder. "We had to refer [the patients] back to the hospital for those services."

NHIC is still paying in-office claims for J2324, says Krista Dauphinee, coding and compliance coordinator with Northeast Cardiology Associates in Bangor, ME. And HGSA still says it'll cover Natrecor for acute decompensated CHF as long as there's physician supervision, but won't cover it as a "bridge to transplantation" except in clinical trials.

Northeast has patients come in twice a week, for four hours each session, and this schedule can last up to 15 weeks depending on a patient's progress, says Dauphinee. Northeast staff will check the patient's BNP levels at every visit to determine how long the patient can keep receiving the medication, she says.

Several other coders and billing managers say they've received visits from drug reps encouraging them to provide Natrecor in the office setting. The drug seemed "costly" and brought up "a lot of time-intensive issues," notes Karen Hopman, director of receivables management with Michigan Heart Group in Troy, MI.

"When it was initially FDA-approved, the majority of the time it was being done in an inpatient setting," notes Cynthia Swanson, management consultant with Seim, Johnson Sestak & Quist in Omaha, NE. Like many other treatments, Natrecor has been migrating toward the office setting. The physician must be on the premises and immediately available to supervise the infusion, and also pay attention to the diagnoses your local carrier lists for coverage, she notes.

It can be very confusing when inconsistent policies mean the coverage for a particular [...]