Optimize Reimbursement for CMV Retinis

Nugget: Be sure to code for all aspects of CMV retinis treatment, including infusion and related supplies, to receive proper reimbursement.

Infectious disease physicians often experience difficulty receiving reimbursement for CMV retinis. The reason, says Barbara Ross Nolet, RN, MA, president of Northwest Management Associates in Gig Harbor, Wash., may be as simple as misunderstanding the ICD-9 codes and the medical necessity for parenteral treatment. This can be cleared up with a letter from the prescribing physician, copies of medical records, or a discussion with the medical director for the payer. The claim also may have been prepared incorrectly, using codes that the payer does not recognize, she adds.

The claims may have been kicked out for review because of the high dollar amounts, or frequency of treatment being provided by a physician office. The payer also may be reviewing the therapy because in their experience it has been provided by a home infusion pharmacy, and billed to the home health, home infusion, or prescription benefit portion of the patients plan, as opposed to the physician services benefit, Nolet explains. The worst-case scenario is that the treatment required preauthorization from either a primary care gatekeeper or a case manager. In that case, you may be able to secure payment for what you have provided already, she adds.

Code Correctly

You want to be sure that the ICD-9 code you use is specific to CMV retinitis. If your claims are in complete denial, as opposed to being paid incorrectly, partially, or at very low reimbursement, there is probably something bigger going on than incorrect codes or poor pricing strategies, Nolet says. To make sure you have billed using the correct codes, however, you need to be sure you know how this therapy would most commonly be billed to a commercial payer (note that all of these codes will not be recognized or paid by your local Part B Medicare carrier), she explains.

The drug itself should be billed using the HCPCS code J0740 (injection, cidofovir, 375 mg) with the appropriate number of units for the actual dosage administered to the patient. Some insurance companies also request the actual national drug code (NDC) number for the vial size of the drug used to compound the dose. Usually, the patient is hydrated with 1.5 liters of normal saline (NS) infused just prior to administering the cidofovir. This will be billed as one unit of J7030 (infusion, normal saline solution, 1000 cc), and one unit of J7040 (infusion, normal saline solution, sterile, 500 ml). Both usually are administered using a pole-mounted, stationary infusion pump to regulate the flow, which would be billed using E0791 (parenteral infusion pump, stationary, single or multichannel) with E0776 (IV [...]

- Published on 2000-07-01