Neurology coding

serfort

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One of our Neurologists wants to being administering the drug Gilenya for MS patients. This is given orally unlike other meds that are infused. Patients given this new drug will still need monitored in the physicians office for up to 6 hours. Does anyone who is familiar with neuro coding have any idea what would be appropiate to bill for monitoring these patients?:eek:
 

MDBlais

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monitering for Fingolimod or Gilenya

Hello Serfort,

I am looking for the same information as you are. Have you received any information?

Thank you,

Michelle
 

MandyFlagg

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Actually just yesterday I met with one of the drug reps and was given some "advice" I am working on making contacts with some of the groups who are already prescribing this medication!
 

serfort

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I have been advised to use an OV code along with prolonged services for the number of hours the patient is bein monitored. Haven't tried it yet so not 100% sure this will work.:confused:
 

MandyFlagg

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No way!

One of my offices is billing office visit codes however that is strictly what it is! Unless your physician is going to sit there with them you cannot bill prolonged services (well non face to face prolonged but those do not pay) I am billing based on counseling/coordination of care and the physician has to see the patient!
 

mshukis

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Gilenya Observation

I have been researching this as well. I believe H0033 (observation oral medication administration) would be an appropriate code. I have been directed to this code when searching online and when I refer to my HCPCS index.

Any comments/opinions?
 

MandyFlagg

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H0033 is listed under Alcohol & Drug Abuse, I did look at this code as well; however after reviewing this codes description and discussing with my compliance manager we did not feel comfortable using this code.

Where did you find this direction online?

What are your thoughts?
 

mshukis

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BCBS MN has an article regarding the reporting of the first dose of gilenya, the policy states to report (the oral med & observation) with H0033. Also, when I look in the HCPCS index for observation it lists H0033. I did notice this code is in the alcohol and drug treatment section but, this particular code's description would fit our needs. I'm still unsure and only wanting to make sure we are coding within guidelines and my provider is paid for every billable service. Thanks for your response(s).
 
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MandyFlagg

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I will have to check that article out, I did look at reimbursement after I saw your post and noone in my area pays for that code. Also, we do not charge for the medication, we get the medication directly from the drug company, this is not something we (or any provider to my understanding) will ever have to pay for as Novartis provides the beginning of the prescription. We have been billing this as an office visit. I am going to look more into this as well!

Thanks
 

MandyFlagg

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Here is an article that I found from the AAN, I do not agree with the prolonged service reference that she makes here because to code a 99355 you must spend >74 min above and beyone the "typical time units"! Also, not sure about your doctors but in our office it is the nurse doing vitals, the doc see's the patient at the very beginning of visit but does not come in every time vitals are taken, the nurse takes them and reports them to the doc. That does NOT qualify for face to face prolonged services EVER! Please let me know what you think of this article.

http://www.aan.com/globals/axon/assets/8351.pdf

It is from May 2011
 

mcpalmeter

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Neurology Coding - Gilenya

I have heard of this drug as well. What exactly is the physician doing to monitor the patient? I understand the time constraints but I am wondering if this isn't something that is really done by a nurse; in which case I would bill the appropriate level of OV provided by the physician based on the 3 key components and the charge for the medication administered. Prolonged service codes with direct face-to-face patient contact require physician attendance. If the physician is not attending to the patient during the 6 hours then the physician should not be paid for the time involved in monitoring. Perhaps the physician would check in on the patient periodically. If this is the case, then the physician could bill for the cumulative face-to-face time as long as it meets the time requirements for billing a prolonged service code (i.e., time in addition to time spent for E/M service).
 

MandyFlagg

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I have heard of this drug as well. What exactly is the physician doing to monitor the patient? I understand the time constraints but I am wondering if this isn't something that is really done by a nurse; in which case I would bill the appropriate level of OV provided by the physician based on the 3 key components and the charge for the medication administered. Prolonged service codes with direct face-to-face patient contact require physician attendance. If the physician is not attending to the patient during the 6 hours then the physician should not be paid for the time involved in monitoring. Perhaps the physician would check in on the patient periodically. If this is the case, then the physician could bill for the cumulative face-to-face time as long as it meets the time requirements for billing a prolonged service code (i.e., time in addition to time spent for E/M service).
In my office the physician sees the patient before the medication is administered, reviews the risks and answers any questions. Then gives the OK for the medication to be given the nurse then does an initial set of vitals and gives the medication and a few min later takes another set of vitals. Then the nurse, at each hour interval, re-takes the vitals and reports them to the physician. Total time spent by nurse/physician is approx 45-50 minutes. I do NOT agree that it would be prolonged services in the least bit however I do believe we could be billing this based on counseling/coordination of care. Thoughts?
 

CJDetaranto

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Gilenya

I too am concerned. The drug company is definitively stating to bill the prolonged codes. The Physician I am working withis planning on seeing the pt for evaluation, history exam and determining the pt is ok for the drug at this visit, then having the PA stay with the patient the entire time. We have one room in the office set aside for IV's. We will use this room for the observation for the Gilenya. Of course the physician is in the office suite and this room is part of the office suite so incident to is acceptable. The PA will do vitals every 15 minutes. Comments?
 

KMABE

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Gilenya

Hi! I bill for a Neurology group. We have been billing Gilenya since Oct. '10. Of course, with any new billing, it basically is a trial and error situation. You try and pick the best code for the service and to be compliant. After a few denials, researching, and studying some of the codes, I have found that it is appropriate to bill an E/M code plus the prolong service code 99354 x 1 unit. We have received payment on our charges. Most of my pt.'s have MCR. I do believe I have one pt. that has UHC. I will say this, my prolong code usually does get denied at first, but when I send in the note, they always come back and pay. I hope this helps.

Karen
 
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Rleeper

With a lot of research I've come to the same conclusion as noted above, The only truly compliant way to bill for this is E/M coding. In working with my Neuro providers this is how we do it however again, it is very necessary to note the quality and quantity of the actual time spent face to face with the patient and only bill for that and any prolonged services. .
 

MandyFlagg

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The only way to bill prolonged is if the physician/PA/NP is with the patient the entire time. The NON-face to face prolonged services do not get paid from what we have encountered. Therefore, if the provider is not with the patient the full 6 hours (or enough time to qualify for prolonged service) you cannot bill the prolonged services. What our neurology office has found that it is not necessary to have a provider in constant attendance of the patient, therefore we are simply using a office visit code, no prolonged service code.
 

RebeccaWoodward*

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Any updates?

Has there been updates for reporting prolonged services for the 6 hour monitoring; in addtion to primary code? I'm just now beginning the research on this.


Thanks for any information.
 
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