Part B Insider (Multispecialty) Coding Alert

Published on Thu Jan 06, 2005 PDF

Some advise J3590 for new miracle MS drug

The Food and Drug Administration approved a revolutionary new drug for multiple sclerosis, Tysabri, back in November. But providers are still coming to grips with coding for this medication.

Physicians will administer Tysabri, also known by the generic name natalizumab, to treat and reduce the frequency of clinical relapses in relapsing forms of MS. The patient receives the drug intravenously every four weeks in either the inpatient or outpatient setting.

"There's no consistent coding or payment strategy for Tysabri yet," notes Neil Busis, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside. But he and other experts offer the following tips on billing for Tysabri:

1. Use chemotherapy codes for the infusion. You'll need to bill for the infusion separately from the drug. Even though Tysabri isn't a chemotherapy drug, Medicare guidelines specify that you should bill chemotherapy administration codes G0359 (up to one hour) and G0360 (each additional hour, one to eight hours) as appropriate.

The Centers for Medicare and Medicare Services' Transmittal 129, dated Dec. 10, 2004, specifies that chemotherapy administration codes will also apply to monoclonal antibody agents and "other biologic response modifiers," including Tysabri. In addition, you would use these codes for parenteral administration of nonradionuclide anti-neoplastic drugs and anti-neoplastic agents for treatment of non-cancer diagnoses.

2. Check your carrier's policy on drug code. In the inpatient setting, CMS says you should bill HCPCS code C9126 for Tysabri, according to Transmittal 423, dated Jan. 6. But CMS doesn't provide any instructions on billing for Tysabri in an outpatient setting. For claims prior to Jan. 1, CMS instructed providers to use unlisted drug code C9399, and some carriers may prefer C9399 after Jan. 1 for Tysabri in physicians' offices.
 
Checking First Is Best

Some neurologists are definitely providing Tysabri in their offices already, says Gina Gjorvad, coding and reimbursement expert with the American Association for Neurology. "I recommended to them that they contact their carrier and find out if they have a coverage policy and how they plan on covering it," Gjorvad says.

So far, one Part B carrier, Cahaba GBA, has issued a policy on Tysabri. Cahaba says providers should bill using unlisted drug code J3590 and list the name of the drug and the dosage in box 19 of the CMS 1500 claim form. The recommended dosage is 300 mg every four weeks, and 300 mg should constitute one unit, says Cahaba (the policy is online at www.msmedicare.com/provider/newsHotNatalizumab_TYSABRI.pdf).

Some physicians are leery of billing for Tysabri when they're not sure what Medicare will reimburse for the drug. "We're not taking on the expense - it's too new," says Michelle Torri, a coder with Associated Neurologists of Southern CT in Fairfield. Instead, Associated Neurologists is sending patients to a specialty pharmacy to obtain Tysabri. Then Associated bills only for the infusion. Tysabri is expensive to stock, and Medicare will change the pricing every quarter. "We just don't know that we won't be operating at a loss" next quarter, Torri complains.