Neurology & Pain Management Coding Alert

Question: We're preparing to start offering Gilenya to some of our patients who have relapsing multiple sclerosis. What things should we include in our documentation and preparation?

Answer: FDA regulations direct providers to monitor a patient for six hours after the initial dose of Gilenya because of the potential side effect of bradycardia (427.8x, Other specified cardiac dysrhythmias) or AV block (426.1x, Atrioventricular block, other and unspecified). Be sure you have a comfortable place for the patient to spend this time, and that your provider adequately documents any checks.

Choose E/M: Because Gilenya is newly approved, some providers still have questions about how to code the service. Review your neurologist's documentation and report the E/M code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) that is supported by the documentation.

Add prolonged service: The patient's initial dose potentially qualifies for prolonged service codes because of the 6-hour timeframe. Calculate the total amount of face-to-face time your neurologist spent with the patient, based on the documentation. Submit +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]) for the first hour. Then add +99355 (... each additional 30 minutes [List separately in addition to code for prolonged physician service]) for each 30-minute time segment until reaching the total.

Be aware: Because Gilenya is an oral medication, payers consider it "self-administered" and will not reimburse your physician for providing the medication. Some practices opt to see the patient, have the patient fill the prescription elsewhere, and then ask the patient to return to the office to take the first dose and be monitored appropriately. Other practices might refer the patient to an infusion center or hospital outpatient department for the administration and monitoring if the neurologist's office  isn't set up to handle the potential cardiac side effects.