Part B Insider (Multispecialty) Coding Alert

Published on Tue Dec 30, 2003 PDF

New drug billing can be touch and go

The Food & Drug Administration approved Natrecor (nesiritide) a few years ago, and it received a HCPCS Code in January 2003. But good luck billing J2324 to many Medicare carriers.

Natrecor is the first of a new class of drugs known as human B-type natri-uretic peptides and is indicated for the intravenous treatment of patients with acutely decompensated congestive heart failure that causes shortness of breath. Studies have shown that Natrecor can improve breathing and heart function in these patients.

But only two carriers have local medical review policies for Natrecor so far. HealthNow New York says flatly that Medicare won't cover the drug. Palmetto GBA says it'll consider the drug on a case-by-case basis.

To win approval with Palmetto, the cardiologist should attach a letter to the claim, "indicating the patient's clinical history, current medications, presenting symptoms or recent hospitalizations, whether or not intravenous inotropic drugs such as dopamine, dobutamine, or milrinone have been tried and failed to improve the patient's heart failure, and the results obtained from using nesiritide on the patient during hospitalization," the carrier's LMRP states.

In other words, Natrecor shouldn't be the first resort in patients with CHF. The carrier also clarifies that the drug should be used only for acute patients, not for chronic CHF sufferers.

Northeast Cardiology Associates in Bangor, Maine, began providing Natrecor in early November, and so far has received reimbursement from its carrier, National Heritage Insurance Corp. NHIC assigned an allowable of $151.62 per 0.5 mg for the drug, and the practice hasn't used more than one dose per time, says Krista Dauphinee, Northeast's coding and compliance coordinator.

"Luckily, we have not been required to send any supporting documentation as of yet," Dauphinee says. Northeast has written its protocols to require the patient to have dyspnea (shortness of breath) on exertion, documentation of CHF requiring "maximal medical management," and a New York Heart Association classification of III to IV, meaning marked limitation of activity or discomfort at any physical activity.

According to Northeast's protocol, patients should also have a brain natriuretic peptide of less than 400, Dauphinee says. But so far, the carrier hasn't asked for any of these records.