Neurology & Pain Management Coding Alert

Staying with basic 99211 might be safest option.

If you're shaky on how to report Gilenya (fingolimod) as a first-line treatment for relapsing forms of multiple sclerosis (MS, ICD-9 code 340), you're not alone. Gilenya questions have circulated ever since the FDA approved the drug in September 2010. Check our answers to three of the most common questions coders have so you'll be ready when your neurologist offers the initial treatment dose to patients.

1. What's the Best HCPCS Code?

"Gilenya is newly approved by the FDA, so there's no HCPCS code for the drug," says Catherine Nolin, CPC, a specialty based coder with Central Main Medical Center in Lewiston.

Result: Your only HCPCS choice currently is J3490 (Unclassified drugs), but verify details before submitting the code. Physicians sometimes write a prescription so patients can obtain and purchase the medication from a local or specialty pharmacy before coming to the office for administration. In those situations, your office should not submit any J code for drug reimbursement.

2. How Should We Code for Monitoring?

When beginning treatment with Gilenya, the FDA recommends observing the patient for a period of six hours. After taking the initial dose of the oral medication, the patient is monitored for signs and symptoms of bradycardia. Your neurologist needs to be available in the office to manage any post-dose arrhythmia-related side effects.

Dilemma: Physicians don't normally track the patient's status following the administration -- a nurse does. The only CPT E/M code allowed for nurse care is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). The code only encompasses five minutes of time -- which is nowhere close to the six-hour initial administration time.

"Our office charges 99211," says Vonda Pickelsimer of Neurology Associates of Greenville, S.C. "Unless the patient has complications so the doctor needs to get involved -- or if the doctor just decides to charge an established follow-up visit by doing an exam before administering the medication that day -- a 99211 is appropriate since the only monitoring required the day of the first dose are the pulse and BP checks."

Caveat: If the neurologist has face-to-face time with the patient prior to the patient taking the initial dose, you'll report an established patient E/M code for the physician visit. You should not report 99211 for the nurse's time during the same patient encounter.

Idea: Offices and MS Care Centers may consider scheduling blocks of time each week for initial Gilenya administration, suggests Anne M. Dunne, RNBC, MBA, MSCN, director of healthcare consulting for Grassi and Company in Jericho, N.Y. "Several patients can be observed and monitored at one time, allowing for more efficient monitoring," she says. "As a bonus, if agreeable, MS patients can interact with each other during the monitoring period, improving their socialization." If you choose to report 99211 or if a nonphysician practitioner provides an E/M service, be sure to follow all incident to guidelines and provide direct supervision.

Potential option: Report 99211 along with 99499 (Unlisted evaluation and management service) to account for the remaining monitoring time. "However, there is no assigned fee schedule for 99499," Nolin points out. "We would have to compare it to the prolonged services codes that are utilized by physicians, not nurses, to receive additional reimbursement."

Appropriate comparison codes could include 99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour [List separately in addition to code for office or other outpatient Evaluation and Management service]) and 99355 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; each additional 30 minutes [List separately in addition to code for prolonged physician service]). If reporting these codes for the six-hour G administration, submit one unit of 99354 and ten units of 99355. The nurse typically would not sit in with the patient during the entire administration; remember to base your "comparable" coding on the actual face-to-face time the nurse spends with the patient, not the entire time the patient spent in the office.

"According to CPT guidelines, the physician must complete all the work face-to-face with the patient before you should report prolonged visit codes," says Lynn McCormack, CPC, a coding auditor with HCA Healthcare. Some vendors, however, say physician offices can obtain written authorization to use the prolonged codes for Gilenya monitoring since there are no other available codes to use --" even though the monitoring was being done by the nurses and not the physicians. "Use caution before jumping to this conclusion, however," McCormack warns.

"The codes must also be in addition to an E/M charge and the time must exceed 30 or more minutes more than what the E/M code descriptor states before you can charge the prolonged codes," Pickelsimer says. "The non-face-to-face prolonged visits are never recognized as payable here in South Carolina."

3. What Will We Be Paid?

If you submit 99211, the code carries total RVUs (relative value units) of 0.58. Payment could be in the vicinity of $19.71 for non-facility providers, based on the national Medicare fee schedule conversion factor of 33.9764.

Provide a established follow up visit with exam prior to Gilenya administration (code 99212 or 99213), and allowed payment could range from $41.45 to $74.85, based upon a work RVU of 0.48 to 0.97, Dunne says.

Aetna is one of the few payers with a published coverage policy for Gilenya. The coverage policy addresses when practices need pre-authorization for the drug itself but doesn't specifically address how providers should report the services associated with the initial in-office administration services. Physician offices must obtain preauthorization and not exceed approved quantity limits and other medical necessity requirements before Aetna considers coverage.

Two final tips: "Remember if your doctor sees the patient for the initial administration, you can code for that with an office visit code (with the level of service determined by the provider's documentation)," McCormack says. And, as experts will remind you, prior authorization is no guarantee of payment.