Neurology & Pain Management Coding Alert

Neurologists who treat patients with Avonex must know the correct coding not only for the diagnosis, but also for the medication, the supplies and patient training to get fully reimbursed. The drug Avonex (generic name Interferon beta-1a) is administered once a week to relapsing multiple sclerosis (MS, 340) patients to slow the disabling progression. It is given intramuscularly and is used therapeutically. The patient may choose to be trained to self-administer the drug or to have a friend or family member trained to help with the injections. Or the patient may elect to have the drug administered by a healthcare professional.   Determining the Diagnosis Code   Before a diagnosis of MS is made, signs and symptoms should be documented in the patient's medical record and used to help establish the primary MS diagnosis. When billing for Avonex therapy, you must ensure that the diagnosis code is used based on an individual determination of the patient's condition using 340, and that proper documentation is included.     Properly Document the Need for Avonex   There are some coding challenges involved with getting paid for treatment with Avonex. Although Medicare generally does not cover drugs that have been identified as self-injectable unless the patient is in a crisis, Avonex is usually covered as long as there is sufficient documentation of medical necessity. According to Veronica Rigsby, supervisor, customer claims, Blue Cross/Blue Shield, Fla., even though they will cover Avonex, the claim must go to a medical review board for approval based on "medical necessity."
To code the medication use J1825 (injection, inter-feron beta-1a, 33 mcg [code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered]). Frequently, it is easier to bill the patient directly. But regardless of who is paying -- patient or insurance company -- you need to code it correctly for your records.  
Most plans cover Avonex, but certain guidelines may apply. Some carriers pay a percentage of the cost, and this amount will depend on whether Avonex is classified as a prescription drug or a major medical benefit. Check with your local carriers. Remember, especially if there is a requirement for substantiating medical necessity, to be sure to have patients sign an advanced beneficiary notice (ABN) to ensure that they understand that they are responsible for the noncovered amount.   Training    Many neurologists are looking for an economical way to teach their patients how to inject themselves with Avonex. The neurologist or staff is also responsible for educating the patient about the possible side effects of the drug and the follow-up lab tests that need to be done. If the patient chooses Avonex training, including injection, and this [...]