Neurology & Pain Management Coding Alert

You need a solid understanding of how to code for Tysabri services to avoid missing out on the maximum payments you deserve -- especially if you-re still coming to grips with CPT infusion codes.

Learn from our experts as they offer you some essential rules to determine which codes to report for administering Tysabri, and you-ll be reaping the reimbursement benefits.

HCPCS: Neurologists typically use Tysabri to treat and reduce the frequency of clinical relapses of multiple sclerosis. Also known by the generic name natalizumab (and formerly called Antegren), it is associated with treatment of multiple sclerosis exacerbations. The correct code for the Tysabri drug is J2323 (Injection, natalizumab, per 1 mg).

Note: HCPCS 2008 replaced Tysabri's temporary Q code with this J code, going into effect on Jan. 1.

ICD-9: Your primary ICD-9 code will most likely be 340 (Multiple sclerosis), representing a diagnosis of MS.

Patients with MS have an 85 percent chance of relapse at the onset, says Howard S. Rossman, DO, FACN, medical director of the MS center of the Michigan Institute for Neurological Disorders (MIND) and clinical professor of neurology at Michigan State University in his presentation, "Setting Up Neurology-Based Infusion Capabilities -- Behind the Rationale and Decision-Making Process" (http://www.mscare.org/cmsc/images/pdf/2005CMSC_Workshop15_allauthors.pdf).

CPT: Typically, the patient receives the drug via intravenous infusion every four weeks in either the inpatient or the outpatient setting. You should code the infusions with 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and possibly the add-on code +96415 (- each additional hour [list separately in addition to code for primary procedure]).

Here's why: Although 96413 and 96415 specify "chemotherapy administration," the codes also apply to infusions of "monoclonal antibody agents and other biologic response modifiers" -- and Tysabri falls into this category, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.

Resource: According to the CPT chemotherapy administration section guidelines, "Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs, and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers."

To ensure you-re receiving the maximum allowable reimbursement for a Tysabri infusion, noting exactly how long an infusion lasts is absolutely necessary.

Protect yourself: Make sure your neurologist accurately documents the start and stop time in the chart.

The rule: You-ll find parenthetical notes with 96415 stating, "Report 96415 for infusion intervals of greater than 30 minutes beyond one-hour increments." That means you shouldn't report 96415 for an infusion of 30 minutes or less beyond the initial hour.

In other words: If a patient has a 90-minute infusion, you should report only 96413 without the add-on code, 96415, because 90 minutes is only 30 minutes past an hour.

Generally, this monoclonal antibody infusion requires between 50 minutes and an hour. If your physician infuses an MS patient with Tysabri, use 96413 for the first hour. If the patient has a mild reaction, your physician may slow the rate of infusion. This may result in a total infusion time of greater than 90 minutes, so you-ll use add-on code 96415 for every subsequent hour.

Good to know: When you-re reporting 96413 and 96415, remember to track the time "based only upon the administration time for the infusion," according to the AMA's CPT Changes 2006: An Insider's View.

Note: With this in mind, you should not count the time spent starting the IV and monitoring the patient post-infusion as billable infusion time. According to the AMA's CPT Assistant (September 2007), "Services leading up to the infusion and following the infusion have been included in the infusion code services and are not reported separately. Therefore, infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping)."

Example: Your neurologist administers an IV infusion of 300 mg of Tysabri. The patient's total time in the office is two and one-half hours, but only 52 minutes count toward actual infusion time. You should code this with 96413 for the infusion.

You-ll complete the claim by submitting J2323 to report Tysabri, along with 300 units in box 24G on the claim form (one unit per milligram).

Your patient's Tysabri infusion may also include separate medication administration services, such as hydration and other medicine infusions, and you should report codes for these services as well.

Example 1: Your patient presents for a scheduled one- hour Tysabri infusion. However, after the physician's assessment, the patient is found to be severely dehydrated. The patient is rehydrated by administering 1,500 cc of IV fluids over a two-hour period.

Your physician determines that the patient can receive the scheduled Tysabri infusion using the same IV access. The total Tysabri infusion time was 105 minutes. The total infusion and hydration time equals three hours, 45 minutes.

For this example, you should report 96413 for the first hour of Tysabri infusion. Then, include one unit of 96415 for the additional 45 minutes of infusion time.

For the hydration, you-ll report +90761 (Intravenous infusion, hydration; each additional hour [list separately in addition to code for primary procedure]) with two units of service for the separate therapeutic secondary service.

Remember that you should link the diagnosis code 276.51 (Dehydration) to support the medical necessity for the separate hydration infusion service. CPT guidelines specify that you shouldn't report IV hydration of 30 minutes or less, and remember to include one unit of J2323 for each 1 mg of Tysabri infused.

Example 2: The patient presents for a Tysabri infusion, but due to a prior minor reaction she was pre-treated with an IV infusion of 50 mg of Benadryl. The pretreatment infusion took 45 minutes, and the Tysabri infusion was over a 95-minute period for a total infusion time of two hours and 20 minutes. For the Tysabri infusion, you-ll report one unit of 96413 and one unit of 96415.

Don't forget: You always need at least 31 minutes of infusion time past the initial hour to code compliantly for the additional hour.

You should also add +90766 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour [list separately in addition to code for primary procedure]) for the Benadryl infusion.

For the drugs, report J2323 for each 1 mg of Tysabri dosage and 1 unit of J1200 (Injection, diphenhydramine HCl, up to 50 mg) for the Benadryl.

FYI: Some payers- claims processing software cannot process three digits in the units of service field. For those payers, you should report the Tysabri as multiple lines of service with a maximum of two digits of service. For 300 mg, for example, you should report four lines of service or J2323 x 99 units, J2323 x 98 units, J2323 x 97 units and J2323 x 6 units. The different units of service will prevent a payer denial of "duplicate charge/line item."

When you-re coding for infusions using chemotherapy administration codes, our experts also recommend keeping the following guidelines in mind:

1. Your neurologist has to be on-site and in the office suite when the patient undergoes the infusion when you bill for Tysabri infusions in a physician's office.

2. Medicare doesn't currently approve ambulatory surgical centers (ASCs) as acceptable locations for infusion therapy.

3. Always be sure to confirm the patient's insurance policy for specific infusion rules and regulations.