Want Remicade Reimbursement? Prove Medical Necessity, Watch the Clock
Published on Thu Jan 01, 2004
Don't trip when billing infusions 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 three rules of thumb for each of your Remicade infusion claims: 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, says Lois Curtis, CPC, of Gastroenterology Associates in Evansville, Ind.
Remicade is "a good treatment, but due to the fact that it's so costly, our doctors try to work with patients to see what treatment is most effective for them," Curtis says.
Payers will want to see proof that your gastroenterologist has tried other methods before using Remicade. It would be wise to include documentation of previous therapies attempted, along with the patient's responses to each of them. 2. Document the Patient's Condition When reviewing the documentation, payers will consider the patient's condition when deciding whether Remicade infusion was justified.
According to Delia Bartolotto-Stewart, CPC, of Digestive Health Physicians in Fort Myers, Fla., insurance carriers are particularly interested in the patient's condition. 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
description of conventional treatments attempted
overall patient well-being. Some offices use the Crohn's Disease Activity Index, a system of measurement that objectively measures how a patient is responding to treatment changes. The index takes into account a number of 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 carrier decide if an infusion regimen is justified.
When billing for Remicade infusions, some gastroenterology offices have gone as far as having a form letter on hand addressing all of the above elements, which they complete and send out along with the bill for the first Remicade injection. Consider creating one of these form letters to be sure you have the proper documentation for your next Remicade-injection claim. 3. Treat Time as a Vital Factor Keeping track of exactly how long a Remicade infusion session lasts is also vital to maximum reimbursement. If your physician injects Remicade in a Crohn's patient, use the 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. Use add-on code +90781 [...]
