Neurology & Pain Management Coding Alert

Question: My neurologist administers Tysabri to a multiple sclerosis patient. How should I report this?


Montana Subscriber

Answer: Tysabri is a monoclonal antibody that falls under the chemotherapy administration services.

You should code the infusions with 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and possibly the add-on code +96415 (- each additional hour, 1 to 8 hours [list separately in addition to code for primary procedure]). 

According to the CPT chemotherapy administration section guidelines, -Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers.-

Generally, infusion takes about 50 minutes to an hour. For this first hour, report 96413. 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 96415 in addition to 96413 to account for the additional 30 minutes of infusion time.

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.
 
To bill for the drug in an outpatient setting for Medicare payers, you should report Q4079 (Injection, natalizumab, per 1 mg).
 
Background: The Food and Drug Administration 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.