Remicaid infusions

Colliemom

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Hi there! I was hoping someone could help us. A patient came in for a Remicaid infusion. The drug was mixed 40 units of the Remicaid drug (J1745), and the infusion started. During the infusion the patient had a reaction and the infusion had to be discontinued. Because the drug was already mixed, the remaining infusion had to be discarded. As you know, Remicaid is a VERY expensive drug, so we are wondering how we can bill for this? The patient did not receive the entire infusion, but once he/she had the reaction the infusion had to be stopped and we had to dispose of the remaining drug. Because it was mixed, it's impossible for us to say how much of the infusion the patient actually received and how much was discarded. How would you bill for this? Are you having any difficulty getting paid?

Also, what are you doing when the following happens?

The patient needs 1 full vial and an additional amount from a second vial to equal the correct dosage that she needs. How are you billing for the unused portion of the second vial?

I did contact Jansen, the makers of Remicaid, and they advised that we call the individual's insurance plan, to see how they want this billed. But the insurance plans are telling us they cannot advise us on how to bill. (so no help there)


thanks!
 
Last edited:

thomas7331

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Medicare reimburses for entire amount of the drugs used, including the discarded portion, but you might need check with your specific payers on how they would like this reported. The JW modifier is available for discarded drugs, but the reporting has not been made mandatory - it was scheduled to become mandatory for July 1, 2016 but was pushed back to 2017.

This is addressed in the Medicare Claims Processing Manual, Chapter 17, linked here, scroll down to section 40:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf

Here's also a FAQ that you might find helpful:

https://www.cms.gov/Medicare/Medica...lOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

For the Remicade infusion you described, I would think there should be a record of how much was administered, even if it was mixed - they should be able to estimate the dosage given based on the percentage of the volume infused; but even if not, for now you can bill for the entire amount.
 

thomas7331

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Just to add, as you mentioned your payers won't tell you how to bill - that's a pretty common response if you call the customer service lines. But the payers should have written policies for this kind of thing, and sometimes you may need to escalate your inquiry a network rep to put you in touch with someone who knows better. But if there truly are no policies, then you're safest bet is to follow CMS. If a payer has no policy, they can't fault you for not following it.
 
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