Neurology & Pain Management Coding Alert

Allow payer's past performance to direct you to current preferences

Chronic reconsideration of Avonex's nature in recent years--and proper coding for its administration--has caused frustration for many neurology offices and comprehensive multiple sclerosis (MS) care centers.

Find out how the most recent changes will affect your reporting, and what hints you can use to determine your payer's current stance on coding.

Get Up to Speed on Coding Revisions

Basics: -Avonex (Interferon beta-1a) is one of the injectable disease-modifying therapies that has been shown to reduce relapse rates and decrease progression of disability in patients with relapsing forms of MS,- says Anne M. Dunne, RN, MBA, MSCN, executive director of the Comprehensive Multiple Sclerosis Care Clinic at South Shore Neurologic Associates PC in Patchogue, N.Y.

History: In January 2005, several Medicare carriers--such as Empire, Health Now, and Group Health Inc.--reconsidered the long-standing categorization of Avonex (Interferon beta-1a) as a therapeutic drug, and instead began to see the complexities of its administration.

As a result, these carriers changed their coding preference for Avonex injections from 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) to G0355 (Chemotherapy administration, subcutaneous or intramuscular non-hormonal antineoplastic). Reason: -G0355 applied because administration of Avonex involved similar complexity and resource use as chemotherapy administration,- Dunne says.

In both cases, you could also code for the Avonex supply itself using Q3025 (Injection, Interferon beta-1A, 11 mcg for intramuscular use). Remember: The standard dose of Avonex is 33 mcg, which means you will most frequently need to report three units of Q3025.

Current challenge: As of Jan. 1, 2006, CMS deleted HCPCS code G0355, leaving some neurology offices wondering what code would be next in the list of Avonex reporting options.

This quandary was complicated by the fact that not all carriers or private payers universally made the switch over to G0355 last year. Instead, some were asking providers to continue using 90782 or G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for Avonex administration.

-Our Avonex representative said that the G0355 wasn't being used yet in Vermont, so we used G0351- for Medicare, says Laurie A. Peacock of Neurological Consultants PC in Bennington, Vt. However, -we used 90782 for payers other than Medicare in 2005,- she adds.

But CPT 2006 also does away with 90782, and CMS deleted G0351 as of Jan. 1.

Bottom line: With the current absence of a national coverage determination, multiple standards for reporting, and recently deleted codes, contacting each individual payer for preauthorization of Avonex will be your best option for proper coding and reimbursement. But you may also be able to use your payer's past performance to deduce its current preferences.

Choose Between 96401 and 90772

In the wake of recent deletions, you are left with two new options for reporting Avonex, both of which are 2006 CPT additions:

- 96401--Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic

- 90772--Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

If you know a payer's 2005 reporting preference, you can make a reasonable determination about which of these codes will now be most appropriate. To do this, you should divide your payers into two categories--those that switched to G0355 in 2005 and those that stuck with 90782 or G0351.

Keep reading: You can stay abreast of any additional coverage determination updates for Avonex with Neurology Coding Alert.