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Gastroenterology Coding Alert

Crohn's Disease Patients Get Remicade After All Else Fails

Published on Sat Mar 12, 2005

G codes for Medicare infusions add another coding twist

This year, reporting your gastroenterologist's Crohn's disease services may be even more intricate than before - particularly if your office uses Remicade (Infliximab) to treat patients with the condition.

Why? Medicare's new set of G codes for infusion, injection and hydration directly affects coding for Remicade infusions. And you'll have to remember acceptable diagnosis codes for Crohn's treatment and reporting drug supplies.

Join us for some expert input on coding Crohn's patients from the first office visit through Remicade infusion. We'll also explain how Remicade reporting will be different for your Medicare patients in 2005.

Consult Typically Leads to Crohn's Diagnosis

A Crohn's patient's initial encounter with a gastroenterologist is typically a consultation requested by the patient's primary-care physician (PCP). The PCP may recognize Crohn's symptoms based on a gastroenterological malady, which spurs the gastroenterologist's involvement, says Lois Curtis, CPC, of Gastroenterology Associates in Evansville, Ind.

When a patient reports to your gastroenterologist for this consultation, the patient does not have a Crohn's diagnosis at this point. Even though the PCP suspects Crohn's, the gastroenterologist must perform additional tests to confirm the condition, Curtis says.

Example: A PCP refers a patient to your gastroenterologist to check for Crohn's disease. The patient has a history of chronic abdominal pain in the lower right quadrant and diarrhea. Based on the findings of a level-two consultation service, the gastroenterologist schedules the patient for a colonoscopy.

Two days later, the gastroenterologist performs a colonoscopy with biopsy to examine the patient's terminal ileum and mucosa.

On the claim, you should:
 

  •  report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision making) for the consultation
     
  •  report CPT 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the colonoscopy
     
  •  attach ICD-9 codes 789.03 (Abdominal pain; right lower quadrant) and 787.91 (Diarrhea) to 99242 and 45380 to account for the patient's stomach pain and diarrhea.  

    Other Symptoms May Also Indicate Crohn's

    The patient in the above example had stomach pain and diarrhea, but the doctor may discover other symptoms of Crohn's disease in a patient, says Bonnie VanderWerf of Marin Gastroenterology in Greenbrae, Calif.

    Crohn's patients whom her gastroenterologist treats may also have the following, VanderWerf says: 

  •  benign neoplasm of the colon (211.3)
     
  •  pernicious anemia (281.0)
     
  •  regional enteritis (555.x)
     
  •  ulcerative colitis (556.x)
     
  •  intestinal obstruction without mention of hernia (560.x)
     
  •  nausea and vomiting (787.0x).

    Patients with any of these symptoms are candidates for further diagnostic testing (such as a colonoscopy with biopsy) to check for Crohn's, VanderWerf says.

    After the testing, the gastroenterologist will "generally wait for the pathology to give a definitive diagnosis of Crohn's disease; you do not want to diagnose someone with Crohn's unless they truly have it," Curtis says.

    For the purposes of this article, let's say the pathology returns and the patient does have Crohn's in an unspecified site (555.9).

    Note: You don't use 555.9 as an ICD-9 code in all instances. Once a patient is diagnosed with Crohn's, you should choose an appropriate code from the regional enteritis family (555.x) to use on all claims related to Crohn's treatment.

    First Treatment Options Are Always Diet, Drugs

    When a patient is diagnosed with Crohn's, the first step in treatment is trying nonsurgical methods to address the condition. "Patients can be treated with drug therapy or diet ... depending on each patient and how they respond," Curtis says.

    One common drug therapy involves medications that contain mesalamine (Sulfasalazine, Asacol, Dipentum, Pentasa). Another option is a regimen of drugs to suppress the immune system - such as 6-mercaptopurine and azathioprine - along with doses of corticosteroids to control inflammation.

    However, if none of these methods helps the patient, the gastroenterologist will usually elect to treat him with infusions of Remicade. It is important to remember, however, that this pricey treatment should only be considered after the gastroenterologist has tried all other options.

    "Usually, our physicians will exhaust drug [and diet] therapy before they try Remicade, since it is so expensive for the patients," Curtis says.

    New Reporting Rules for In-Office Infusions

    When reporting to private payers, you will still report Remicade infusions with the same infusion codes you did in 2004.
     
    However, if your physician performs an in-office Remicade infusion on a Medicare patient, your codes will be different in 2005, says Matthew Lautzenheiser, senior administrative manager at Johns Hopkins Medicine in Baltimore.

    Example: A patient with Crohn's in an unspecified site reports to the office for Remicade treatment. The gastroenterologist infuses 300 milligrams of Remicade over a two-hour period.

    On a claim for a private payer, you should:
     

  •  report 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the first hour of infusion
     
  •  report +90781 (... each additional hour, up to eight hours [list separately in addition to code for primary procedure]) for the second hour of infusion
     
  •  attach ICD-9 code 555.9 to 90780 and 90781 to prove medical necessity for the infusion
     
  •  report J1745 (Injection, infliximab, 10 mg) x 30 for the Remicade supply.

    On a claim for a Medicare payer, you should:
     

  •  report G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) for the first hour of infusion
     
  •  report G0360 (Each additional hour, 1 to 8 hours)    for the second hour of infusion
     
  •  attach ICD-9 code 555.9 to G0359 and G0360 to prove medical necessity for the infusion
     
  •  report J1745 x 30 for the Remicade supply.

    Hot tip: "Typically, with Remicade infusions, the physician will use saline to infuse the pharmaceutical. You can bill for that supply, using J7050 (Infusion, normal saline solution, 250 cc) for every 250 cc administered," Lautzenheiser says.

    Caveat: Remember that these coding tips are solely for instances when your gastroenterologist performs Remicade infusions in-office. A gastroenterologist may not report infusion therapy performed in a hospital inpatient or outpatient setting.

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