Neurology & Pain Management Coding Alert

Choose from C9399, C9126 or J3590 for drug supplies

As with most infusion drugs, you should report Tysabri treatments using at least two codes: one for the drug itself and another for the infusion procedure.
 
If you're reporting Tysabri for Medicare payers, you can be sure of using HCPCS G codes for infusion, but getting paid for the drug may require that you contact the individual carrier for instructions. And coding for non-Medicare payers is still a free-for-all (see "Private Payers Pose Unique Challenges for Tysabri," later in this issue, for more information).

Background: The FDA approved Tysabri, also known by the generic name natalizumab (and formerly called Antegren), in November 2004 to treat and reduce the frequency of clinical relapses in relapsing forms of multiple sclerosis. The patient receives the drug via intravenous infusion every four weeks, in either the inpatient or outpatient setting.

"Because Tysabri is so new, many payers and providers are still trying to sort through the available information," says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine. "At this point, the most important question for Medicare is how to bill for the drug supplies in the outpatient setting."
 
Use G Codes for Infusion
 
You should report Tysabri infusions to Medicare payers using new-for-2005 HCPCS codes G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) and G0360 (... each additional hour, one to eight [8] hours [list separately in addition to code for primary procedure] use G0360 in conjunction with G0359).

Generally, infusion takes about 50 minutes to an hour, Busis says. For this first hour, report G0359. If, due to mild patient reactions, the provider must slow the rate of infusion, leading to a total infusion time of greater than 90 minutes, you report G0360 in addition to G0359 to account for the additional 30 minutes of infusion time, says Anne M. Dunne, RN, MBA, MSCN, administrator for the Comprehensive Multiple Sclerosis Care Clinic at South Shore Neurologic Associates PC in Patchogue, N.Y.

Caution: You may not bill additional codes for the required one-hour observation period following Tysabri infusion, even if the provider leaves the IV in place, Dunne says.

Call on C Code for Inpatient Drug To bill for the actual drug in an inpatient setting for Medicare payers, you should list HCPCS code C9126 (Injection, natalizumab, per 5 mg). These instructions appear in CMS transmittal 423, dated Jan. 6, 2005.

Important: As transmittal 423 is written, CMS does not provide definitive instructions for claiming Tysabri supplies in an outpatient setting.

"CMS hasn't proscribed using C9126 in the outpatient [...]