Neurology & Pain Management Coding Alert

You'll still need direct supervision

If your neurology practice provides in-office injections of Avonex for MS (340, Multiple sclerosis) patients, now's the time to change your reporting strategy. Effective this year, you should be claiming G0355 - rather than 90782 - for the injection.

Make the Switch to the G Code

Although some payers still treat Avonex as a "self-injectable" drug, you may charge Medicare carriers for injections provided in the office, as outlined by Medicare transmittal AB-02-072.

Beginning Jan. 1, 2005, you should report all Avonex injection services using new-for-2005 G code G0355 (Chemotherapy administration, subcutaneous or intramuscular non-hormonal antineoplastic). Until this year, the correct code for this service was 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

Good news: "It would appear Avonex is now being recognized as the biologic it is, and its administration coding is now similar to that of chemotherapy agents. This should result in greater payment for the administration of the drug," says Anne M. Dunne, RN, MBA, MSCN, administrator for the Comprehensive Multiple Sclerosis Care Clinic at South Shore Neurologic Associates PC in Patchogue, N.Y.

Don't be fooled: Avonex is not a chemo drug, but G0355 applies because administering Avonex involves similar complexity and resource use as chemo infusions.  

Check With Payers

Several carriers have begun to accept G0355 for Avonex injections. To date, however, only one local Medicare payer - Empire Medicare Services, which provides Part B coverage for a 16-county area in New Jersey and southeastern New York - has released a local coverage determination (ID number L11653, titled "Interferon Beta-1A") outlining the change.

Translation: Because carriers other than Empire have not yet gone on record as accepting G0355 for Avonex injections, you should contact your carrier prior to submitting your claims to be sure that the carrier has made the switch. To protect yourself, be sure to ask for the carrier's instructions in writing.

Private payers could differ: The instructions to use G0355 for Avonex apply specifically to Medicare. Some private payers may observe different guidelines.

"Although most, if not all, private carriers recognize the G codes, there may be some that still have not 'changed over,' " Dunne says. For non-Medicare payers, therefore, you should preauthorize the Avonex administration code to verify which code the carrier wants you to use.

Supplies Are Separate

If the neurologist supplies the Avonex from his own stores, you may charge extra for the cost of the drug supplies, says Lori Eck, CCS-P, CCP, CEO of Seabreeze Medical Billing and Collection Inc., in Pt. St. Lucie, Fla. The appropriate code for this is Q3025 (Injection, interferon beta-1A, 11 mcg for intramuscular use).

A full dose of Avonex is 33 mcg. Therefore, you should report three units of Q3025 per full dose administered.

According to the Empire Medicare coverage determination, "HCPCS code J1825 [Injection, interferon beta-1a, 33 mcg] and HCPCS code Q3026 [Injection, interferon beta-1a, 11 mcg for subcutaneous use] are not valid for Medicare use."

Direct Supervision Is Mandatory

Finally, under Medicare guidelines, the neurologist must administer the Avonex personally or incident-to her services and under her direct supervision. "Direct supervision" means that the neurologist must be present in the office area and be immediately available to offer guidance and direction if either is needed during the injection. The neurologist need not, however, be present in the room when the patient receives the injection.