Primary Care Coding Alert

Family practices can now receive reimbursement for intravenous immune globulin treatment (IVIg) on Medicare patients with five specific mucocutaneous blistering diseases.
 
"Although these are rare diseases, we sometimes see patients with them," says Daniel Fick, MD, director of risk management and compliance for the College of Medicine Faculty Practice Plan at the University of Iowa in Iowa City. "Usually, the patients have been evaluated by a dermatologist and then sent to their family physician for continued IVIg treatment." 
 
CMS announced Jan. 31, 2002, that it will cover IVIgs for patients with the following diseases:

 

pemphigus vulgaris (694.4)
 

pemphigus foliaceus (694.4)
 

bullous pemphigoid (694.5)
 

mucous membrane pemphigoid, a.k.a. cicatricial pemphigoid (694.60 or 694.61)
 

epidermolysis bullosa acquista (757.39).

In addition, CMS requires that patients fall into three categories:

 1) Patients who have failed conventional therapy
 2) Patients in whom conventional therapy is otherwise contraindicated
 3) Patients with rapidly progressive disease in whom a clinical response could not be effected quickly enough using conventional agents. In such situations IVIg therapy would be given along with conventional treatment(s), and the IVIg would be used only until the conventional therapy could take effect.

Although CMS issued the announcement as a national coverage decision, certain parameters vary by carrier. "Each carrier will define what constitutes failure of conventional therapy as well as what represents contraindications to conventional therapy," says Ronald Dei Cas, MD, a medical officer in the Coverage and Analysis Group of CMS.
 
FPs using the IVIg treatment on Medicare patients should report 90283 (Immune globulin [IgIV], human, for intravenous use). Also, bill for the administration with 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous). Include the corresponding diagnosis code for one of the five diseases.
 
For example, a 60-year-old female with chronic bullous pemphigoid presents after an acute flare-up of the disease. She had side effects from previous medications, so her dermatologist puts her on IVIg, and she comes to the FP for her treatment. Code this visit with 90283 for the IVIg treatment, and use 90784 for the administration. Link 694.5 to 90283 and 90784. If the patient presents to the FP and a full evaluation is performed to determine that she needs new treatment, an office visit E/M code (99201-99215) can also be billed, says Fick.
 
Some payers may prefer that coders attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code indicating that is was significant and separately identifiable from the IVIg treatment. Medicare, however, may not reimburse for both the administration code and the E/M code, even with the -25 modifier. Medicare normally does not cover administration codes billed with E/M services. Because this is a new coverage decision, that standard may not apply in this case. Coders should ask local carriers their preference.  
 
"After a patient is started on the IVIg treatment, he or she will start coming in regularly, usually every four weeks or so," Fick says. "When the patient comes in for consistent treatment, you can code for the IVIg and the administration but not the office visit. That's only billable on the original visit when you determine they need the new treatment."
 
When a dermatologist refers a patient to the FP for regular treatment, practices can only bill for the IVIg treatment and the administration because the dermatologist already performed the initial evaluation.
 
"IVIg may be used with other conventional therapy, as well," Dei Cas says. "The conventional immune suppressive treatments often have a lag time before they show therapeutic effect, while the IVIg has a more rapid onset. In some cases, the physician will put the patient on the IVIg while he is waiting for the conventional therapy to show effects." If Medicare covers the conventional therapy, practices can be reimbursed for using both treatments at the same time, until the conventional therapy takes effect.
 
Medicare pays for short-term therapy of IVIg but not for maintenance therapy. Dermatological experts recommend a treatment course lasting a maximum of six months; however, the definition of short-term therapy will be at each carrier's discretion. Check with your local carrier to determine this.
 
CMS officials say it may be a while before they release implementation instructions, so coverage questions should be directed to individual carriers.
 
Note: To view the CMS decision memo on IVIg treatment, go to www.hcfa.gov/coverage/8b3-kkk2.htm.