Internal Medicine Coding Alert

Published on Tue May 01, 2007 PDF

Question: An established patient with Crohn's disease in his colon reports to the internist for a Remicade infusion. During the 120-minute session, the internist infuses 200 mg of Remicade. During the infusion, the internist also infuses 250 cc of saline. How should I report this encounter?

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Answer: You should be able to report a pair of CPT codes and a single J code on the claim:

 • 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour of Remicade infusion

 • +96415 (... each additional hour [list separately in addition to code for primary procedure]) for the second hour of Remicade infusion 

 • 555.1 (Regional enteritis; large intestine) linked to 96413 and 96415 to represent the patient's condition

 • J1745 (Injection, infliximab, 10 mg) x 20 units for the Remicade supply.

 You do not get to code extra for the saline infusion (J7050, Infusion, normal saline solution, 250 cc). According to your scenario, the saline was given concurrently, meaning the saline infusion is bundled into the Remicade infusion.