Neurology & Pain Management Coding Alert

Choose from C9399, C9126 or J3590 for drug supplies

As with most infusion drugs, you should report Tysabri treatments using at least two codes: one for the drug itself and another for the infusion procedure.
 
If you're reporting Tysabri for Medicare payers, you can be sure of using HCPCS G codes for infusion, but getting paid for the drug may require that you contact the individual carrier for instructions. And coding for non-Medicare payers is still a free-for-all (see "Private Payers Pose Unique Challenges for Tysabri," later in this issue, for more information).

Background: The FDA approved Tysabri, also known by the generic name natalizumab (and formerly called Antegren), in November 2004 to treat and reduce the frequency of clinical relapses in relapsing forms of multiple sclerosis. The patient receives the drug via intravenous infusion every four weeks, in either the inpatient or outpatient setting.

"Because Tysabri is so new, many payers and providers are still trying to sort through the available information," says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. "At this point, the most important question for Medicare is how to bill for the drug supplies in the outpatient setting."
 
Use G Codes for Infusion
 
You should report Tysabri infusions to Medicare payers using new-for-2005 HCPCS codes G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) and G0360 (... each additional hour, one to eight [8] hours [list separately in addition to code for primary procedure] use G0360 in conjunction with G0359).

Generally, infusion takes about 50 minutes to an hour, Busis says. For this first hour, report G0359. If, due to mild patient reactions, the provider must slow the rate of infusion, leading to a total infusion time of greater than 90 minutes, you report G0360 in addition to G0359 to account for the additional 30 minutes of infusion time, 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.

Caution: You may not bill additional codes for the required one-hour observation period following Tysabri infusion, even if the provider leaves the IV in place, Dunne says.

Call on C Code for Inpatient Drug

To bill for the actual drug in an inpatient setting for Medicare payers, you should list HCPCS code C9126 (Injection, natalizumab, per 5 mg). These instructions appear in CMS transmittal 423, dated Jan. 6, 2005.

Important: As transmittal 423 is written, CMS does not provide definitive instructions for claiming Tysabri supplies in an outpatient setting.

"CMS hasn't proscribed using C9126 in the outpatient setting, but neither has it provided instructions that you should," Busis says. "So far, CMS instructions have pertained only and specifically to inpatient coding for Tysabri supplies."

Outpatient Supply Code Still Uncertain

For claims prior to Jan. 1, 2005, CMS instructed providers to report C9399 (Unlisted drugs or biologicals) for Tysabri supplies. Because Medicare has stated that C9126 is appropriate in the inpatient setting (but has provided no overriding instruction for Tysabri given in the outpatient setting), some carriers may still prefer C9399 for Tysabri supplies in a neurologist's office or other outpatient facility.

Payer tips: Some payers may also prefer a HCPCS J code for Tysabri supplies. For instance, one Part B carrier, Cahaba GBA, has issued a policy on Tysabri instructing providers to bill using unlisted drug code J3590 (Unclassified biologics) and to list the name of the drug and the dosage in box 19 of the CMS 1500 claim form.

Another payer, New York Part B Carrier Empire Medicare, initially instructed providers to submit claims for natalizumab using HCPCS code J3490 (Unclassified drugs). Only days later (Feb. 7, 2005), however, the same payer revised its instructions, directing providers to submit claims for natalizumab using J9999 (NOC, antineoplastic drug).

In other words: There's still a lot of uncertainty and unpredictability right now. Without first contacting your payer or watching its policy updates closely, you can't be sure how to report drug supplies for Tysabri at this time, Dunne says.

Additional supply tip: Along with the infusion administration and drug supply codes, you may also report the dilutent used to reconstitute the Tysabri, Dunne says. The provider must dilute the Tysabri in 100 cc of 0.9% sodium chloride, preservative-free. For the sodium chloride supplies, report HCPCS code J7051 (Sterile saline or water, up to 5 cc) and document the correct number of units to reflect the amount of solution the provider uses.

Additional documentation tip: Payers often require that you list the National Drug Code (an 11-digit number), strength/dose, unit description and the route of administration in field 19 of the CMS 1500 claim form, or the claim will most likely result in a denial, Dunne says.

Get in Touch With the Carrier

Some neurologists have already taken the plunge and are providing Tysabri in their offices, says Gina Gjorvad, coding and reimbursement expert with the American Association for Neurology.

To be safe, however, Gjorvad recommends that providers contact carriers ahead of time to ask about coverage policies. Request instructions in writing and follow them to the letter. And, keep your eye out for policy changes in coming months.