Gastroenterology Coding Alert

Although most insurance plans cover infusion treatment of infliximab (Remicade) for Crohn's disease regardless of setting, optimum, ethical reimbursement hinges on reporting accepted ICD-9 codes, administering covered dosages and submitting necessary documentation. Report the Infusion When a gastroenterologist administers Remicade, you should use infusion code 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the first hour and add-on code +90781 ( each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) for each subsequent hour.

"Generally, I bill for two subsequent hours of infusion since the recommendation is that a patient is infused over a three-hour period of time," says Kimberly Ingoldsby, billing supervisor for Albany Gastroenterology Consultants P.C., a nine-physician practice in upstate New York. A claim for such a treatment would read:

90780 +90781 +90781. Note: Some local medical review policies (LMRPs), such as Cigna's Medicare Part B policy for Tennessee, require that you indicate in the days/units field the number of hours of infusion beyond the first hour. If the physician supervises a nurse practitioner, the same codes apply. "A registered nurse infuses each patient, checks vitals routinely throughout the infusion and is in constant attendance for the duration of the infusion," Ingoldsby says. "A physician must be present within the suite for a patient to receive an infusion. Although the registered nurse is infusing, he or she is working under the supervision of a medical doctor."

When the nursing staff independently provides the infusion, bill a nurse visit (99211). The nurse code applies to established patients only. "If the doctor hasn't first seen the patient, you can't bill 99211," says Mary Anne Burke, billing manager, Gastroenterology and Internal Medicine Group in Hartford, Conn. Do not report 99211 in addition to 90780. "The first hour [of intravenous infusion] includes the nurse's time, the monitoring and other services. Chances are insurers may pay 99211 rather than 90780."

However, a patient who comes in for an infusion and has a different problem warrants a separate E/M, she says. Ingoldsby adds that her doctors would perform both procedures "as long as the problem did not present itself as a contraindication for the infusion." To indicate that the service was separate and unrelated to the infusion, you must append 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.

If the physician performs an E/M service related to the Crohn's disease and documents the E/M service, you should also bill for the E/M service at the level appropriate to the problem and documentation (99212-99215, Office or other [...]