Neurology & Pain Management Coding Alert

Neurologists who treat patients with Avonex must know the correct coding not only for the diagnosis, but also for the medication, the supplies and patient training to get fully reimbursed. The drug Avonex (generic name Interferon beta-1a) is administered once a week to relapsing multiple sclerosis (MS, 340) patients to slow the disabling progression. It is given intramuscularly and is used therapeutically. The patient may choose to be trained to self-administer the drug or to have a friend or family member trained to help with the injections. Or the patient may elect to have the drug administered by a healthcare professional.

 

 

Before a diagnosis of MS is made, signs and symptoms should be documented in the patient's medical record and used to help establish the primary MS diagnosis. When billing for Avonex therapy, you must ensure that the diagnosis code is used based on an individual determination of the patient's condition using 340, and that proper documentation is included.  

 

 

There are some coding challenges involved with getting paid for treatment with Avonex. Although Medicare generally does not cover drugs that have been identified as self-injectable unless the patient is in a crisis, Avonex is usually covered as long as there is sufficient documentation of medical necessity. According to Veronica Rigsby, supervisor, customer claims, Blue Cross/Blue Shield, Fla., even though they will cover Avonex, the claim must go to a medical review board for approval based on "medical necessity."

To code the medication use J1825 (injection, inter-feron beta-1a, 33 mcg [code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered]). Frequently, it is easier to bill the patient directly. But regardless of who is paying -- patient or insurance company -- you need to code it correctly for your records.  

Most plans cover Avonex, but certain guidelines may apply. Some carriers pay a percentage of the cost, and this amount will depend on whether Avonex is classified as a prescription drug or a major medical benefit. Check with your local carriers. Remember, especially if there is a requirement for substantiating medical necessity, to be sure to have patients sign an advanced beneficiary notice (ABN) to ensure that they understand that they are responsible for the noncovered amount.

 

Training 

 

Many neurologists are looking for an economical way to teach their patients how to inject themselves with Avonex. The neurologist or staff is also responsible for educating the patient about the possible side effects of the drug and the follow-up lab tests that need to be done. If the patient chooses Avonex training, including injection, and this is performed by a nurse under the neurologist's supervision, 99211 (office or other outpatient visit) would be billed. The nurse, however, must dictate a note for the chart with mention of the patient's condition and any discussion between the nurse and the patient.

 

If the nurse provides the patient education with a regular office visit, also use 99211 to report the E/M service. CPT states that 99211 "may not require the presence of a physician," which means it can be used to report services provided by a nurse. The description goes on to say that "typically, 5 minutes are spent performing or supervising these services. 

 

The problem with this code is that Avonex training may take anywhere from thirty minutes to over an hour. It is a two-step process. The nurse must teach the patient (or the patient's friend or family member) how to administer the drug. Unfortunately, 99211 is the only code that can be used to report the administration of these services by a registered nurse -- regardless of the amount of time actually spent with the patient. Unless the physician sees the patient, 99211 is the only billable code. It is not surprising that many neurology offices find the compensation for 99211 to be insufficient for the time spent.

 

Note: Codes 99401-99404 (preventive medicine, individual counseling) cannot be used to report services performed by a registered nurse, and the counseling provided with these codes must be preventive in nature, not related to a diagnosed condition.

 

In some cases, the patient may bring in their own supply of the drug if the neurologist has written a prescription. This may need to be done if reimbursement for the drug does not cover its cost. To code for only the injection, use 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Enter J1825 on the HCFA 1500 with a $0 amount. This will indicate to the payer what was injected.

 

It is possible, on an individual payer basis, that a clinical nurse specialist (CNS), a certified nurse practitioner (CNP), a physician assistant (PA), or other Medicare qualified provider performing Avonex training could use a more comprehensive code (e.g.,: 99212-99215) if the counseling dominated (comprised more than 50 percent of) the visit. If a CNP performed the training and the visit only met the criteria of a 99211 visit, but the training lasted an hour instead, the code level selection would be based on time. In this situation, the CNP would then use 99215 for the level that includes "counseling or coordination of care" in which a physician "typically spends 40 minutes face-to-face with the patient and/or family."

 

 

Section 2049 of the Medicare Carriers Manual states, "Drugs that are self-administered are not covered by Medicare Part B unless the statute provides for such coverage ... If a physician gives a patient an injection which is usually self-injected, this drug is excluded from coverage, unless administered to the patient in an emergency situation (e.g., diabetic coma)."

Many local Medicare carriers allow clinicians to bill for the administration on a one-time-only basis at the initiation of the therapy, if the drug requires dose titration to test the patient's responsiveness and appropriate dosage, or if the clinician is demonstrating how the patient should administer it.

 

Medicare's rationale is that a primary caregiver should be available to perform the injections if the patient cannot. If no caregiver is available and the patient receives the injections in the neurologist's office, he or she may be responsible for payment. Be sure to check with the patient's insurance carrier to confirm coverage. 

 

If the patient does not wish (or may be too disabled) to self-administer, and the neurologist gives the injection, use both 90782 and J1825. Check with your carrier before billing, because state-to-state and carrier-to-carrier variations may apply.  

 

Tip: In determining your practice's reasonable and customary (R & C) charges for injectable drugs, the Physicians Desk Reference is a good source that gives you the average wholesale price (AWP). Come up with a formula for your practice based on the AWP. Medicare, for example pays 90 percent of the AWP. Most practices bill at 120-175 percent of the AWP. 

 

Use HCPCS Supply Code for Syringes

 

Carriers routinely deny the purchase of syringes for patients who plan to self-inject at home. The denials say the syringes are considered "part of the original procedure code and should not be billed separately" or "not covered." Frequently, even carriers that cover syringes for office injections do not reimburse the patient, but rather informs them that the supply is covered if it is coded correctly, implying that they would be paid if the office coded differently. Tina McElhaney, billing/surgical coordinator of the Atlanta Center, Ga., reports that she has tried a number of different ways to get reimbursed for the patient's syringes. She explains, "I tried billing the same for these syringes as we do for the ones we use when the patient's injection is done in the office using procedure codes." This would be coded as 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered) and A9270 (HCPCS non-covered item or service). However, most of these claims were not reimbursed.

 

McElhaney writes "syringes" in the space next to the code on the claim form. In the units box, she writes "1 box of 25 for self-administered injection." Since she began doing so, more claims are being reimbursed. 

 

There is an existing HCPCS code for the syringes -- A4211 (supplies for self-administered injections). Most carriers require this specific code, rather than 99070, which is a generic supply code that has to be accompanied by a description.

 

Coders should still contact payers and find out whether they prefer 99070 or A4211. Depending on the individual carrier's policy, they may not pay for the A4211 separately. A couple of offices reported that switching to electronic billing helped eliminate some of their problems with reimbursement of syringes.

 

 

As with all drugs, there are potential side effects with Avonex that will often result in a visit to the neurologist's office. For these visits, use a low-level office visit code 99201 (problem focused history and examination) and 99202 (expanded problem-focused history and examination) and be sure to document the patient's symptoms such as muscle ache and chills (780.9); headache (784.0); or weakness (780.7).