by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Jun 6th, 2016 - Reviewed/Updated Aug 2nd
Most third-party payers (eg, commercial insurers, Medicare, Medicaid) cover REMICADE® (infliximab) for its approved U .S . Food and Drug Administration indications (see Indications on page 5 of this guide) . However, benefits may vary depending upon a patient’s insurer or specific insurance plan (or “product”) offered by a payer.
When third-party payers review claims for REMICADE®, first they will determine if the reported service is covered under their contract or rules . Most payers cover drug infusions as part of their core benefits. Next, payers will look for evidence supporting the medical necessity of therapy.
This evidence may include:
•Information about the patient’s medical condition and history
•A physician’s statement or letter of medical necessity
•Supporting literature (eg, peer-reviewed studies and compendia monographs)
•Prescribing information
•Availability of other treatment alternatives
Administrative issues may also affect coverage of therapy with REMICADE® . For example, payers may consider the following:
Does the payer’s contract specifically preclude physician offices from billing for infusion services or infused drugs?
A small portion of payers have exclusive contracts with designated preferred providers for infusion services . This may include certain clinics or specialty pharmacies that deliver drugs to healthcare providers or other infusion centers .
Does the payer cover the therapy only when provided through a specific treatment site?
Payers may have site-specific coverage rules that restrict provision of infused therapies .
For example, currently Medicare does not cover infusions when they are billed by Medicare-certified ambulatory surgery centers . Medicare and other payers also may restrict coverage for certain infused drugs in the home or hospital outpatient setting .
Is the billing provider a “participating” member of, or “in-network” provider, for that particular plan?
Payers contract with providers to deliver services to the plan’s members . Providers are thus
“participating” or within that plan’s network, requiring them to abide by the contract charge structure when providing care for that plan’s members.
Did the patient obtain the appropriate referral or prior authorization if required by their plan?
Many plans require that non-emergency services be pre-approved or that a primary care physician make the referral for specialty care . Failing to obtain appropriate referrals or pre-authorization can result in non-payment by the plan.
REMICADE® Billing UnitsThe HCPCS code for REMICADE® is
J1745, described as: “Injection infliximab, 10 mg .” Thus, each 10-mg dose equals one billing unit, or 1/10th of a vial. It is important to understand that when billing for REMICADE®, each 100-mg vial of drug represents 10 units of
J1745 . The following chart illustrates the correlation between vials, milligrams, and billing units.
|
Number of 100-mg vials
of infliximab
|
Number of mg |
Number of billing units based on J1745
(10 mg inflisimab per unit)
|
| 1 |
100 |
10 |
| 2 |
200 |
20 |
| 3 |
300 |
30 |
| 4 |
400 |
40 |
| 5 |
500 |
50 |
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
Billing, Documentation and Billable Units. (2016, June 6). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/billing-documentation-and-billable-units-31599.html
© 2016 InnoviHealth Systems Inc
Quick, Current, Complete - www.findacode.com