Wiki 96413 versus 96365

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cjrottum

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I have been coding infusions for a Rheumatologist for a while and he always codes the admin codes of 96413/15 with the monoclonal antibody drugs. We are getting denials on several of these: Actemera, Orencia, Tysabri and Simponi Ari and the billing department is just changing to 96365 to get them paid. My question from him is (he is pretty upset) these are monoclonal antibodies and per several Rheumatology articles he has he can and should be the chemo infusion codes with these drugs.

Have you run into this issue and, if so, what did you decide to do?

Help!!
 
I can vouch for the Tysabri is billed with the chemo infusion codes 96413. We have no problems getting payment.

I can't vouch for the others at this time.
 
I bill for a rheumatologist and he uses the 96413 also. Which insurance is denying them?
The reason I ask is that a couple years ago a particular carrier wanted a different admin code.
 
The billing department is telling us that they are all getting denied and they just change it and then it gets paid. I have been in the dark about this since I turned the Rheum coding over to another one of our coders to concentrate on GI coding for a new ASC we acquired but she is going on vacation and mentioned this to me since I will be covering her coding. I felt that this is incorrect based on the fact that these drugs are monoclonal antibodies and require more nursing and physician supervision.

I have requested that the billing department notify me which insurances, specifically, are denying, what the denial codes are, etc.

Does anyone know of a reference I can use regarding this (a CPT asssistant, Rheumatology article or somethign)?

Thanks!
 
https://www.noridianmedicare.com/pa..._list_of_drugs_usually_self_administered.html

Here is the link above that the billing department is providing us. Under the lists of drugs is a question:

Q3. We have been using the chemotherapy administration codes for administration of these drugs. May we continue using those codes?

A3. No. The preamble to the chemotherapy administration section of the CPT Manual is very specific about the circumstances that permit use of these codes (96401-96417). The administration of these three drugs do not meet the criteria specified in this section, instead, an appropriate code from the 96365-96376 section should be selected to represent administration of one of these three drugs.

Noridian has published an article regarding the use of the chemotherapy administration codes; the most recent version is in ?Medicare A News? Issue 2109 dated June 27, 2013 and ?Medicare B News? Issue 287 dated August 15, 2013. An updated version will appear soon.



Here is the medicare part B news link: https://www.noridianmedicare.com/sh...2013/287_aug/Chemotherapy_Administration_.htm

This states clearly that monoclonal antibodies are considered billable with chemo admin codes but then goes on to give a list of J codes and Q codes that are billable with these and the J codes for Tysabri, Actemera, etc are not included in that list. I feel that this information is conflicting itself but we are getting denials on these drugs when billed with the chemo admin codes.

I don't know where to go to find anymore information about this as I have discussed with other clinics that are still using chemo admin codes.
 
It depends on the payor policies. We have WPS Medicare. Tysabri is to be billed as non-chemo for them. When speaking to a representative they told me that because Tysabri is located in under their "Drugs and Biologicals (Non-Chemotherapy) policy, it must be billed with a non-chemo admin code. That being said, if it gets submitted accidentally as a 96413 it will pay be we were also told that this may open the door for an after payment audit. Remember, just because something pays, does not mean it is correct.
As far as the other drugs that you were asking about, they are not found in either the chemo or non-chemo policy for WPS.
 
I also agree with the others who have responded the 96413/96415 are the correct codes to bill based on the nature of the meds being given. You may need to status these claims yourself to get the correct reason for the rejection. Don't trust your back end department as it is obvious they aren't knowledgeable about this area of coding and billing.
 
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