Optimize Reimbursement by Properly Coding Remicade for Rheumatoid Arthritis

Remicade has received FDA approval for treatment of rheumatoid arthritis (RA), notes Dianna Hofbeck, RN, CCM, president of North Shore Medical Inc., in Absecon, N.J., and previously has been used in the treatment of Crohns disease. There is still confusion, however, on how to code and document for Remicade. Obtaining preauthorization and understanding documentation requirements are crucial to reimbursement as is correct coding when billing for Remicade in outpatient infusion therapy (OPI).

(For more information on how to avoid losing reimbursement see the box OPI Is Key to Avoid Losing RA Reimbursement on page 11.)

Keys to Correct Coding

Remicade usually is infused over two to four hoursunless there are complications that cause the infusion to be slowed down or discontinued. Effective Jan. 1, 2000, the drug was assigned HCPCS code J1745 (injection, infliximab, 10 mg). When it was first approved, however, there was no specific HCPCS code for Remicade and code J3490 (unclassified drugs) generally was used on Medicare claims.

Note: Check with your local carrier to make sure they recognize the new code.

The frequency of administration as well as dosage levels are determined by the patients weight, age, diagnosis, clinical status and response to other treatment, such as methotrexate (J8610, oral; J9250, J9260, sodium). Documentation can make the difference between getting paid and not getting paid, Hofbeck adds. The appropriate diagnosis codes are 714.0 (rheumatoid arthritis) and 714.2 (systemic rheumatoid arthritis).

Note: The National Drug Code (NDC) number for Remicade is 57894-0030-01.

Three to four vials are the usual dose based weight at 5mg per Kg, according to Contocor, the manufacturer of Remicade. Frequency and dosage are quite variable, but usually are administered at Week 0, 2 and 6 of the treatment. The patient then may receive this treatment every eight weeks for the rest of his life, explains Hofbeck.

According to Barbara Ross Nolet, RN, MA, president of Northwest Management Associates consulting firm in Gig Harbor, Wash., however, it is unlikely that the patient would need a long-term venous access device or be taught to administer the drug at home. In any case, she points out, Medicare would not cover home administration of the drug.

In addition, Hofbeck notes, the average wholesale price (AWP) of the drug is $611.33 per 100-mg vial. But, she says, Medicare usually pays about 80 percent of AWP.
Here are Hofbecks specific coding instructions for using Remicade in OPI on RA patients: The units per billing unit is 10mg=1U.

You can charge for the first hour of infusion (90780) and additional hours (90781) or as chemotherapy, first hours (96410) or additional hours (96412). You also can charge for a peripherally inserted central catheter (PICC) line insertion (36010), infusions supplies (99070) [...]

- Published on 2000-04-01