Internal Medicine Coding Alert

Question: An established patient with Crohn's disease of the large intestine reports to the internist for a Remicade infusion. Infusion time started at 1:30 p.m. and ended at 3:12 p.m. During the encounter, the internist also performed a 10-minute Benadryl infusion to prevent nausea. Notes indicate the internist used 200 mg of Remicade and 45 mg of Benadryl. How should I report this encounter?

North Dakota Subscriber

Answer: You should be able to report a pair of infusion codes for the Remicade, and another code for the Benadryl administration. However, the brevity of the Benadryl infusion means you should opt for a non-infusion code.

Check out this coding advice, broken into two parts to make it more understandable:

Part 1 -- Remicade: The total infusion time for the Remicade treatment was one hour and 42 minutes, meaning you can report the initial infusion code for the first hour plus an add-on code for the remaining 42 minutes. On the claim, report the following for the Remicade infusion:

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

• +96415 (... each additional hour [list separately in addition to code for primary procedure]) for the remaining 42 minutes.

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

• J1745 (Injection, infliximab, 10 mg) x 20 to represent the Remicade supply.

(Only report 96415 when you are coding for at least 30 minutes of infusion time. So if a Remicade infusion lasts one hour and 20 minutes, for example, you would report only 96413.)

Part 2 -- Benadryl: Remember, you can code separately for any antiemetics the internist provides the patient during a Remicade infusion.

But since the Benadryl infusion was less than 15 minutes in duration, you should consider it a push and report +90775 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [list separately in addition to code for primary procedure]) with 555.1 attached.

Also, report J1200 (Injection, diphenhydramine HCl, up to 50 mg) for the Benadryl supply.