Neurology & Pain Management Coding Alert

Revised CMS guidelines allow you to collect as much as $20 per injection

If you've been getting denials for your Avonex injections, you need to fight back. Although Avonex was long classified a "self-injectable" drug, current CMS regulations allow physicians to receive payment for administering Avonex to multiple sclerosis (340) patients.

Report 90782 for Injection

If the neurologist administers an Avonex injection for a patient, you should report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) to describe the service, says Steven Dibert, MD, a practicing neurologist at the Neuroscience and Spine Center in Gastonia, N.C.

Prior to August 2002, CMS classified Avonex as a self-administered drug. And, "Drugs that are usually self-administered are not covered by Medicare Part B ... 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)," according to the Medicare Carriers Manual.

Here's the good news for your practice: In May 2002, CMS released Program Memorandum AB-02-072, which allows payment for certain self-injectable drugs, including Avonex, beginning Aug. 1, 2002. This can mean roughly an additional $20 per injection for your practice, based on 2004 Physician Fee Schedule database figures.

If you receive denials for Avonex injections from your Medicare payer, be sure to appeal the claim and cite program memo AB-02-072 (available on the CMS Web site www.cms.gov; use the "search" function to locate the memo) as proof of the validity of your coding.
 
Report Q3025 for the Drug

If the physician supplies the Avonex, you must also bill for the drug itself using HCPCS supply code Q3025 (Injection, interferon beta-1A), says Lori Eck, CCS-P, CCP, CEO of Seabreeze Medical Billing and Collection Inc., in Pt. St. Lucie, Fla.

In some cases, the patient may bring his own supply of the drug (if the neurologist has written a prescription, for instance) to the office for injection. In this case, you should continue to report 90782 for the injection and Q3025 on the CMS-1500 claim form. However, you should place a $0 amount next to the Avonex supply code. This will indicate to the payer what the physician injected (and thus you will fulfill the definition of 90782 by "specify[ing] the material injected") while preventing incorrect payment, Eck says.

Use E/M Codes for Training

Patients self-administering a drug usually need training to learn the proper method of injection. Typically, a nurse or other nonphysician practitioner can provide this service in-office and charge for his time using 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), Dibert says.

"I would recommend that the training take place an a separate day than the injection. Payers are increasingly rejecting claims of 99211 and 90782 on the same day, even with modifier -25 [Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] appended to the E/M code," Dibert adds.

You can bill for the nurse's time: Code 99211 "may not require the presence of a physician," Eck says, which means you may use it to report services that a nurse provides. The CPT descriptor for 99211 goes on to say, "Typically, 5 minutes are spent performing or supervising these services." But the nurse must dictate a note for the chart with mention of the patient's condition and any discussion between the nurse and the patient.

The problem with reporting 99211 is that Avonex training may take from 30 minutes to more than an hour. Unfortunately, 99211 is the only code that you may use to report the administration of these services by a registered nurse -- regardless of the amount of time actually spent with the patient.

Not surprisingly, many neurology offices find the compensation for 99211 to be insufficient for the time spent, but 99211 is your only chance to receive some compensation for the service. But if the physician sees the patient to provide training and administers the initial injection on the same day, you may be able to justify a higher-level E/M service if documentation supports it, Eck says. Remember to append modifier -25 to the E/M code.

Note: You may not use preventive medicine codes 99401-99404 to report services performed by a registered nurse. And, because 99401-99404 describe preventive services, you should not link them to an already diagnosed condition.

Turn to E/M Codes for Side-Effect Visits, Also
 
As with all drugs, Avonex may cause side effects that will result in the patient's visiting the physician's office. For these visits, use a low-level office visit code such as 99211 or 99212 (depending on the documented levels of history, exam and medical decision-making) and be sure to document the patient's symptoms, such as muscle ache and chills (780.9x), headache (784.0), or weakness (780.7x), as appropriate.