Discontinued Infusion Therapy

Greensboro, NC
Best answers
I received a call today from infusion and was wondering if you have dealt with a situation such as this. They had a patient receiving infusion therapy today; drug was Remicade. The patient began having an adverse reaction to the drug and infusion was then stopped. The patient had been in therapy for about an hour before they had to stop the Remicade. They are billing w/J1745 for drug, J7050 for saline solution and 96413 for therapy. They state they were told they had to use the -53 modifier because it was discontinued which I agree with. They also state they were advised that if they used the -53 modifier they would not be reimbursed (or could not bill) for the drug. I'm not sure that I agree with that last statement.
Infusion is arguing that they have to be reimbursed somewhere for the drug that is wasted since it is discarded when the therapy is stopped. They cannot bill the patient and wanted to know why they wouldn't be reimbursed by insurance.

My thoughts are that they are trying to use the -53 modifier on the drug (J1745) which you cannot do and may be the reason they were told they wouldn't get paid for it. I'm thinking you would only bill for the therapy 96413 adding the 53 modifier to it showing it was discontinued but you would bill the regular way for the drug (# of units used) and you wouldn't use a modifier on the J1745 or the J7050. Someone suggested we use JW modifier for the discarded portion but after reading Medicare's guidelines i'm not sure they could do that either.

Another question the office had……..they had to keep the patient for an additional hour to monitor her due to the adverse reaction. She was not receiving therapy for this last hour it was just observation. They want to know if they can bill separately for that as well since it is considered a complication and if so what code would they use to report it?

Please advise on how you would bill for the therapy/drugs in this situation and if they are able to bill separately for the observation of the adverse reaction.

Any insight you could give would be greatly appreciated!