Eli's Rehab Report

Long classified as a "self-injectable" drug, Avonex administration hasn't been reimbursable by Medicare, and multiple sclerosis (MS, 340) patients who were unable to self-administer were forced to pay out-of-pocket for a practitioner's help in injecting it.

But thanks to a new CMS ruling, physiatrists can finally collect reimbursement for administering Avonex injections to MS patients. On May 15, 2002, CMS released Program Memorandum AB-02-072, which allows payment for certain self-injectable drugs, such as Avonex, beginning Aug. 1, 2002.

Physiatrists are well aware of the Medicare Carriers Manual guideline stating, "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)."

"With the new ruling, CMS better defined the self-injectable guideline by saying that if less than 50 percent of the user population of a certain drug can self-inject a product, the drug will be considered covered by Medicare," says Arney Rosenblat, public affairs director at the National Multiple Sclerosis Society. Because "Avonex is an intramuscular drug, it fell under the umbrella of that ruling and is now reimbursable."

To bill for Avonex administration, PM&R practices should use 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) along with HCPCS J1825 (Injection, interferon beta-1a, 33 mcg) for the drug itself.

The Correct Coding Initiative (CCI) lists 90782 as a component of code 97601 (Removal of devitalized tissue from wound[s]; selective debridement, without anesthesia ...), but modifier -59 (Distinct procedural service) can be appended to override this edit if both codes represent separately identifiable services. For example, an MS patient presents for an Avonex injection. During the injection, the nurse discovers that a previously healed pressure ulcer has opened and requires debridement. The nurse can bill for the debridement using 97601 with the ICD-9 for the sore (707.0), and also for the injection using 90782-59, with 340 as the ICD-9 code.

PM&R practices should expect to see some patients who still choose to self-administer Avonex. Many MS patients prefer not to leave the house each time an injection is necessary, and instead have a family member or assistant perform the injection. In these cases, the PM&R practice can bill for training the patient (and the patient's helpers) to self-inject the drug.

This training session should be coded as 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician). Unfortunately, this code is meant for a five-minute nurse's E/M visit, whereas Avonex training can take an hour or more. Therefore, reimbursement for the training does not support the amount of time spent with the patient.

Following the training session, some PM&R practices give their patients a supply of syringes for their self-injections of Avonex. These should be coded as A4211 (Supplies for self-administered injections).

The new CMS program memo offers local Medicare carriers criteria to determine whether a drug is "usually" self-administered. Individual carriers should release their own coverage guidelines for these drugs in the coming months.

You can view the program memo on self-injectable drugs at the CMS Web site by visiting www.hcfa.gov/ pubforms/transmit/AB02072.pdf.