5 Easy Steps Snag Every Avonex-Related Dollar
Published on Thu Nov 19, 2009
Your carrier-supply pay hinges on using Q, not J, code.
When coding for Avonex injections, you'll leave money on the table unless you get the allowed combo of administration, supply, E/M, and ICD-9 codes.
Capture all ethically allowed payments with these important steps:
Step 1: Apply Chemotherapy Code for Admin
"Avonex is now being recognized as the biologic it is," says Anne M. Dunne, RN, MBA, MSCN, Senior Vice President, Clinical Service Development, National Medical Management Services in Port Washington, NY. Coding for Avonex administration is now similar to that of chemotherapy agents. "This should result in greater payment for the administration of the drug," she says.
Since Avonex meets the criteria for a complex biologic agent look to administration codes 96401-+96417, which are for the injection and IV infusion of chemotherapeutic, other highly complex drugs, or complex biologic agents. Avonex is typically administered into a muscle (intramuscular). Therefore, code the administration as 96401 (Chemotherapy administration, subcutaneous or intramuscular).
Step 2: Make Sure 96401 Meets Incident-To Criteria
If auxiliary personnel provide the injection under incident-to, the physician must directly supervise the procedure. That means, he must be present in the office suite during this procedure. Alternatively, the neurologist could perform the injection and bill it directly.
Otherwise, if your Avonex records are ever audited, the carrier could request paybacks for payments. Medicare may not cover the treatment if this part is not properly documented.
Step 3: Use J or Q Supply Code Based on Payer
Include the supply code for Avonex. Currently,HCPCS offers the following codes for Avonex:
• J1825 -- Injection, interferon beta-1a, 33 mcg
• Q3025 -- Injection, interferon beta-1A, 11 mcg for intramuscular use.
For treatment of multiple sclerosis, Avonex is usually given intramuscularly (IM) at 30 mcg dosage once weekly. Therefore, you can use J1825 and Q3025 for Avonex.
Red light: Medicare discontinued J1825 years ago, says Angela DeRitis, CMM, billing manager for South Shore Neurologic Assoc. PPC, in Long Island, N.Y. Medicare policies will pay for the drug only under Q3025 and instruct coders to also bill 96401 for administering the drug. The Medicare Physician Fee Schedule classifies J1825 as "I" (Not valid for Medicare purposes) and has no allowance in the quarterly Medicare Average Sales Price files.
Bottom line: To ensure proper reimbursement from Medicare, report the Avonex injection using Q3025 with three units of service.
Step 4: Add E/M-25 by Looking for 2 Details
Use modifier 25 on an office visit code (99201-99215) only if the neurologist performs a separately identifiable and significant E/M service in addition to the chemotherapy administration and documents it. Make sure to properly document the service, stresses Nellie Bonilla,CPC, of the Clinic for Neurology in Huntsville, Ala.
Checking the patient's status can clue you in to whether an office visit might be codeable in addition to the injection. For patients seen by the physician prior to injection, use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), DeRitis suggests. If the patient comes in for a routine scheduled IM injection, this in many cases would not support an E/M service with modifier 25.
Don't miss: If the patient receives training to self-administer the Avonex injection or education on the injection's side effects, code the services based on the provider. If only the nurse performs these services, use 99211 (Office or outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...). If the neurologist performs the patient education, you would use the appropriate level E/M, such as 99212-99215 with 25.
Step 5: Use a 3-Digit Diagnosis Code
To report in-office Avonex injections, you have to enter only three digits for the diagnosis code. For MS, use 340 (Multiple sclerosis), one of the few valid three-digit ICD-9 codes.
Check with your major payers on covered conditions. Cigna covers clinically definite multiple sclerosis (CDMS) and relapsing remitting multiple sclerosis (RRMS). Aetna requires that the patient have either CDMS or laboratory-supported MS. Humana requires prior authorization (PA) for coverage (download the form from the insurer's Web site).
