Neurology & Pain Management Coding Alert

Revised CMS guidelines allow you to collect as much as $20 per injection

If you've been getting denials for your Avonex injections, you need to fight back. Although Avonex was long classified a "self-injectable" drug, current CMS regulations allow physicians to receive payment for administering Avonex to multiple sclerosis (340) patients. Report 90782 for Injection If the neurologist administers an Avonex injection for a patient, you should report 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) to describe the service, says Steven Dibert, MD, a practicing neurologist at the Neuroscience and Spine Center in Gastonia, N.C.

Prior to August 2002, CMS classified Avonex as a self-administered drug. And, "Drugs that are usually self-administered are not covered by Medicare Part B ... If a physician gives a patient an injection which is usually self-injected, this drug is excluded from coverage, unless administered to the patient in an emergency situation (e.g., diabetic coma)," according to the Medicare Carriers Manual.

Here's the good news for your practice: In May 2002, CMS released Program Memorandum AB-02-072, which allows payment for certain self-injectable drugs, including Avonex, beginning Aug. 1, 2002. This can mean roughly an additional $20 per injection for your practice, based on 2004 Physician Fee Schedule database figures.

If you receive denials for Avonex injections from your Medicare payer, be sure to appeal the claim and cite program memo AB-02-072 (available on the CMS Web site www.cms.gov; use the "search" function to locate the memo) as proof of the validity of your coding.
 
Report Q3025 for the Drug If the physician supplies the Avonex, you must also bill for the drug itself using HCPCS supply code Q3025 (Injection, interferon beta-1A), says Lori Eck, CCS-P, CCP, CEO of Seabreeze Medical Billing and Collection Inc., in Pt. St. Lucie, Fla.

In some cases, the patient may bring his own supply of the drug (if the neurologist has written a prescription, for instance) to the office for injection. In this case, you should continue to report 90782 for the injection and Q3025 on the CMS-1500 claim form. However, you should place a $0 amount next to the Avonex supply code. This will indicate to the payer what the physician injected (and thus you will fulfill the definition of 90782 by "specify[ing] the material injected") while preventing incorrect payment, Eck says. Use E/M Codes for Training Patients self-administering a drug usually need training to learn the proper method of injection. Typically, a nurse or other nonphysician practitioner can provide this service in-office and charge for his time using 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...), Dibert says.

"I would recommend that the training take place an a separate day [...]