Wiki Remicade and add'l dexamethasone treatment

[ollielooya]

Hello colleagues,
I've posted this same question to another outside forum I frequent but figured this dedicated rheumatology forum might yield quicker answers. Here's the case:

Pt. receives Remicade infusion in the doctor's office over a period of l hour and 48 minutes = 96413 and 96415.

Additionally 125 mg. of Dexamethasone was infused over a half hour.
The Dexamethasone is not a usual medication to give during the Remicade treatment, and is only given due to a significant flare up of patient's condition or for a reaction to the medication. The use of code 96366 is being denied as "representing an add on code that is only considered for reimbursement when reported with a primary procedure that is also considered for separate reimbursement." They have their own edits per the National Reimbursement Forum and 96366 is not on their list when accompanying CPT codes 96413 and 96415.

Can someone more knowledgable with this type of procedure please validate whether or not our doctor's choice of code 96366 is the best choice? Would not 96367 ACTUALLY fit this type of service and in light of this a corrected claim be the proper way to go as this particular carrier does accept 96367 with 96413/96415. Just wanting some opinions before taking any recommendation to the physician.

I may need additional followup from the list members from responses received.

 

[Ryannwoike]

I would show the dr. that the 96366 does not add on to 96413-96415 but the 96367 does apply to the 96413, and I would r/s a corrected claim with the correct 96367 for the dexa infusion I did rheumatology for 7 yrs and always showed the dr. where he went wrong and once he saw it in writing he would change the codes for me

 

[umcanes4]

Since you can only have 1 primary/initial infusion code (and in this case it's the remicade 96413) per encounter, the seq infusion of the new drug (dexamethasone) that infused up to 1 hour (which the dexamethasone did) would be coded as 96367.

I would explain the scenario to the Dr that if say the Remicade infused 1hr 48 mins & Dexamethasone infused an 1hr 31 mins then you can use 96413, 96415, 96367, 96366.

You can show them the part in the CPT book under 96367 where it states "report 96367 in conjunction w/96365, 96374, 96409, 96413 to identify the infusion of a NEW drug provided as a secondary or subseq service after a diff initial service is administered through the same IV access."

Hope this helps