Internal Medicine Coding Alert

Published on Thu Mar 01, 2001 PDF

Remicade infusions offer added reimbursement for internists treating patients who are among the more than 2 million Americans (mostly women) suffering from the painful, debilitating effects of rheumatoid arthritis. In January 2001, Remicade (infliximab) became the first drug inhibiting the progression of joint damage in patients with rheumatoid arthritis to be approved by the U.S. Food and Drug Administration (FDA). Internists ready to use this new arthritis therapy must follow certain prequalification criteria before service can begin.

Use Infusion Codes to Report New Therapy

John Harshbarger, MD, a rheumatologist at Carolina Arthritis Associates, a four-rheumatologist facility in Wilmington, N.C., says that each infusion treatment for Remicade takes about three hours. When reporting Remicade infusions for the first hour use 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), and for each additional hour use 90781 (... each additional hour, up to eight hours [list separately in addition to code for primary procedure]), says Harshbarger. We normally bill two units of 90781. The drug itself can be reported with HCPCS supply code J1745 (injection, infliximab, 10 mg).

Apart from the drug and infusion codes, internists can bill for a disposable drug delivery system (A4305), a saline fee (J7130) and insertion of a catheter (36000).

Remicade is a monoclonal antibody used to block tumor necrosis factor alpha (TNFa), which is a key mediator in the inflammatory process. Infliximad neutralizes biological activity of TNFa by binding with high affinity to the soluble and transmembrane forms of TNFa, inhibiting TNFa from binding with its receptors.

For the past 15 years, methotrexate had been the so-called gold standard for treating rheumatoid arthritis. Methotrexate is a prescribed medicine taken orally, normally once a week. On the other hand, Remicade is administered by IV, usually in an outpatient setting (i.e., an internal medicine office).

Have Treatment Precertified

Melody Duncan, manager of accounts receivable at Carolina Arthritis Associates, a four-rheumatologist facility in Wilmington, N.C., says all patients receiving Remicade treatments are precertified for insurance coverage because of the expense. Insurance precertification for treatment of Remicade should be initiated by the internist or billing manager. Precertification can also be done through an affiliated group of the manufacturer.

We have an electronic form that we fill out and forward to Centocor (Health Care Solutions). They make all the checks to verify the patients coverage, says Duncan. When we get that form back we go over it to see if the carrier may also require a letter of medical necessity. This normally takes the form of a note indicating that the patient has failed to respond to other treatments, particularly methotrexate.

Prequalifying Factors for Treatment

Medicare carrier guidelines in North Carolina and Kansas specify that a diagnosis of rheumatoid arthritis (714.0) is required before treatment can begin and that the patient must also be receiving concomitant methotrexate therapy. I believe this requirement is in place because the methotrexate and Remicade combination was used in the recent (two-year) trial, says Harshbarger. We actually have one patient who had a severe reaction to methotrexate that precluded using it, but we requested an insurance waiver to treat him with Remicade alone and his response has been excellent. I presume the FDA will conduct further studies on the efficacy of Remicade with and without methotrexate. For now, providers cannot get reimbursed for Remicade treatment without methotrexate therapy.

Note: Medicare guidelines state that providers should include the following information in block 19 of the HCFA 1500 form: concomitant methotrexate therapy, including the methotrexate dosage and the patients weight.

Get Reimbursed for Dosage

Remicade is packaged in single-use, 100-mg vials. When billing Medicare, one billing unit equals 10 mg. Depending on the patients weight, each infusion of Remicade usually falls between 20 and 60 units based on the drug volume/patient weight ratio of 3 mg/1 kg.

Remicade, manufactured by Centocor of Malvern, Penn., is not cheap. Roberta Berry, billing supervisor at Mid-America Rheumatology Consultants, a six-rheumatologist practice in Overland Park, Kan., says their office bills $850 per vial. That makes the average cost per infusion, using two to three vials, between $1,700 and $2,550.

Nancy Becker, MD, a rheumatologist at Mid-America says her group follows the manufacturers recommended infusion schedule, beginning at zero weeks, two weeks, six weeks and every eight weeks after that. That puts the average annual cost of the medication alone somewhere between $12,000 and $15,000.

Remicade is not a cure, says Becker. The treatments are an on-going proposition, and its presenting a real challenge to insurers. On the other hand, its by far the best treatment yet developed for relieving pain and preventing the progression of joint damage in patients with rheumatoid arthritis.

Harshbarger calls Remicade a cost-effective treatment. Yes, the cost of the treatments are daunting, he says, but if its preventing joint destruction, then how many joint replacement surgeries are we avoiding farther down the road.

Consider Time When Providing Service

There appears to be some doubt about how to code for additional infusion hours because the CPT code is not specific for fractions of hours.

Jim Stephenson, a coding consultant who operates an independent billing service in Elyria, Ohio, says that if an infusion took two hours, 35 minutes, he would bill 90780 and then round up to three hours and bill two additional units of 90781. However, if it took two hours, 25 minutes, he would round back two hours and bill 90780 and one additional unit with 90781.

As a result of the time consumed for each Remicade infusion, internists may administer the drug to the patient at a hospital, although it could be done in the office or other outpatient setting.

Billing Remicade Incident to

Kathy Pride, CPC, CCS-P, an internal medicine coder and coding supervisor at Martin Memorial Medical Group in Stuart, Fla., says that after the diagnosis for rheumatoid arthritis has been established and the patient has been cleared for Remicade insurance coverage, coders must remember there is no office visit involved in a scheduled infusion treatment.

Because Remicade cant be self-administered to be covered by Medicare, the medication can be billed as an incident to service.

Internists should note that the guidelines for IV infusion codes (90780-81) stipulate that the IV is to be administered by physician or under direct supervision of physician . . .

The key phrase is under direct supervision of physician, which according to the Medicare Carriers Manual, reference 2050.1 (Incident to Physicians Professional Services), section B, paragraph 3, does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

Pride says this allows the physician sufficient leeway to do other things. The doctor just has to be sure to remain on the premises in those situations, she says.

Billing E/M With a Remicade Treatment

Harshbarger says he tries to avoid billing for an E/M visit on the same day as a scheduled infusion. We always check to see how the patient is doing, but its not often that this leads to where were providing a significant and separately identifiable service. If we do, we must attach 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 service code (99211-99215) and make certain we document the reason in the patients chart.

If were doing a followup to treatment, its our policy to schedule it on a different day. One exception would be if a patient had to travel some distance. We would try to limit their inconvenience by giving a treatment and E/M on the same day.

Pride also cautions coders not to confuse IV drip infusion (90780-81) with IV push injection (90784, by needle injection). People sometimes get these confused, she says, emphasizing that Remicade is always administered by drip infusion.