Gastroenterology Coding Alert

Learn how you can collect for saline infusions as well Insurance carriers will pay for Remicade infusions for patients with moderate to severe cases of Crohn's disease, but you can't just jot down the J code and drop the bill in the mailbox.

Abide by the following four steps for each of your Remicade infusion claims: Step 1: Document the Other Therapies Tried There are several treatment options that could curb Crohn's symptoms before Remicade becomes a reality, such as oral medications containing steroids or mesalamine, dietary changes, and nutritional supplements. Trying other treatments first will also benefit the patient, experts say.
 
Payers will want to see proof that your gastroenterologist has tried other methods before using Remicade. Therefore, you should include documentation of previous therapies attempted, along with the patient's responses to each. Step 2: Have Patient's Condition Clearly Explained When reviewing the documentation, payers will consider the patient's condition when deciding whether a Remicade infusion is justified.
  
Hot tip: Most of the time, they will expect that an office has documented each of the following before green-lighting a Remicade payment:
 - severity of abdominal cramping/pain
 - severity/frequency of diarrhea
 - extraintestinal manifestation(s)
 - the presence of any fistula, abscess or mass
 - description of conventional treatments attempted
 - overall patient well-being
 - the results of pretreatment tuberculosis (TB) testing (Note: TB testing is now standard of care, and you can separately code this using 86580, Skin test; tuberculosis, intradermal.) Red flag: Just because payers may be looking for these details, you should always base your claim on what your gastroenterologist documents.
 
Some offices use the Crohn's Disease Activity Index, a system that objectively measures how a patient is responding to treatment changes. The index takes into account several factors, including frequency of bowel movements, pain, well-being, weight changes, blood counts and other symptoms related to Crohn's disease. A description of how Remicade therapy would improve the condition of the patient may also help the payer decide if an infusion regimen is justified.
 
Step 3: Treat Time as a Vital Factor Keeping track of exactly how long a Remicade infusion session lasts is also vital to maximum ethical reimbursement. -Physicians will document the start and stop time in the chart,- says Melissa Scolese, revenue management auditor for the DuBois Regional Medical Center in DuBois, Pa.

If your physician infuses a Crohn's patient with Remicade, use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour. Use add-on code +96415 (... each additional hour, 1 to 8 hours [list separately in addition to code for primary procedure]) for every subsequent hour.
 
Remember: Although 96413 and 96415 specify -chemotherapy administration,- the codes also apply to infusions of -monoclonal antibody agents and [...]