Neurology & Pain Management Coding Alert

CPT codes 90780/90781 for infusion are a possibility

The best way to know how to report Tysabri infusions to third-party (non-Medicare) payers is simply to pick up the phone and give the payer a call. With no national policy to unify their approach, private insurers have adopted a host of conflicting guidelines.

Infusions Could Call for CPT or HCPCS

 For some private payers, you may be able to follow CMS regulations and report 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]) for Tysabri infusion.

Payers may just as likely, however, instruct you to use CPT IV codes 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]), 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.

Good news: The difficulty reporting Tysabri infusion could clear with the release of next year's CPT manual. The AMA will adopt several new infusion codes in 2006 that will take the place of the G0359, G0360, 90780 and 90781, according to CMS predictions.

Drug Supply Codes Repeat Medicare Uncertainty

When billing for Tysabri drug supplies, you could, once again, call on the Medicare-approved outpatient code (C9126, Injection, natalizumab, per 5 mg) or the more general C9399 (Unlisted drugs or biologicals) or the unclassified supply code J3590 (Unclassified biologics), or some other code of the payer's choosing, depending on the payer and whether you provide the service in an inpatient or outpatient setting. Again, the only way to be sure is to contact the payer and ask for its guidelines.

S Codes May Help for Some Payers

In at least one case, the payer won't let you report a supply code at all. Highmark Blue Cross/Blue Shield, an insurer in Western Pennsylvania, has set up its own drug supply system. Physicians must obtain drugs for Highmark patients through the insurer's own pharmacy and therefore cannot charge separately for the drug supply. This is known as the "specialty pharmacy" model, as opposed to the traditional "buy and bill" model.

To combat physician complaints that simply charging for the infusion does not cover practice costs, however, Highmark does allow physicians to report S9430 (Pharmacy compounding and dispensing services), instead of a supply code and in addition to the infusion code(s), when the insurer provides the drug.

Alternative: You could ask patients to supply the Tysabri themselves.

Some physicians are leery of billing for Tysabri supplies when they're not sure how or what payers will reimburse for the drug.

"We're not taking on the expense. It's too new," says Michelle Torri, a coder with Associated Neurologists of Southern CT in Fairfield, Conn. Instead, Associated Neurologists is sending patients to a specialty pharmacy to provide Tysabri, and then Associated is billing only for the infusion.