Part B Insider (Multispecialty) Coding Alert

Published on Sat Feb 05, 2005 PDF

3 options for easing the cost of tricky first dose

Sometimes when a new miracle drug hits the market, you may need a miracle to obtain payment for it.

A case in point is the drug Apomorphine, sold under the name Apokyn by Mylan Bertek Pharmaceuticals. Although Apokyn has been around for years, the Food and Drug Administration just approved the drug last year for patients immobilized by Parkinson's disease.

Many Medicare carriers won't cover Apokyn because the patient can self-administer it. One carrier, Wisconsin Physicians Insurance Service Corp., announced it would cover Apokyn incident-to a physician's services . With other carriers, you might have to charge the patient for the drug and injection. But that's not the main problem with Apokyn reimbursement.

Administering the patient's first dose of Apokyn is a complex and time-consuming matter, explains Frederick, MD, neurologist Marc Raphaelson. Medicare's typical reimbursement for an office visit scarcely covers the cost of the service, he adds.

"It takes a lot of patient time in the office," notes Raphaelson, who is on the American Academy of Neurology's medical economics and management committee and Bertek's speakers' bureau.

First of all, the patient must come in for a preliminary visit during which the physician decides to prescribe Apokyn. The patient should have failed trials of multiple Parkinson's drugs. The physician must pay attention to any history of cardiac disease or orthostatic hypotension, which requires special caution. The physician prescribes an anti-nausea drug, trimethobenzamide, for at least three days before the first dose of Apokyn. This is likely to be a high-level office visit.

But the visit at which the physician administers the first dose of Apokyn must be much more time-consuming. This is partly because the patient must be in the "off," or immobilized, state - meaning the patient won't have taken his or her medications that morning and will have a hard time getting into the office. Then the physician must check how the patient is tolerating the anti-nausea drug and make sure the patient hasn't had any falls or illnesses that could keep the patient from starting Apokyn.

2 Hours in Office Up Visit Costs

After the injection, the physician must keep the patient in the office for two to three hours and keep checking on the patient at regular intervals. The patient also must have a nurse present at all times. Because the physician's total face-to-face time with the patient isn't likely to be too high, the physician may not be able to bill for prolonged services.

But the physician must absorb the cost of having the patient in the suite for a few hours, plus the nurse's salary. And for all that, the physician may only receive $80 to $100. "There are very few physicians who can afford to absorb the cost of an exam room and a nurse for two and a half hours while only getting paid for an office visit," says Raphaelson.
 
Try 3 Ways to Up Payment

Considering the extreme underpayment for this service, the fact that many patients are having a hard time obtaining Apokyn is not surprising. Raphaelson knows of 15 patients in his area whose physicians haven't yet figured out how to provide the drug without losing too much money. He says there are a few options:

1) One university hospital plans to admit patients overnight for their first dose of Apokyn. The hospital bears the facility cost and bills Medicare for a short stay.

2) Some other short-stay facilities, such as a hospital observation unit or ambulatory infusion unit, may be able to take on the patient.

3) The patient could hire a nurse from a home health provider, and the nurse could accompany the patient to the physician's office for the first dose. That way, the physician is only on the hook for the cost of the suite.

Bottom line: "The office codes are not well set up to deal with a situation like this," says Raphaelson.