No, this claim is lacking proper documentation to be billed out correctly and requires querying the provider before submitting to the payer.
First, a query is a written or verbal question concerning the documentation of what is being billed out and should be visible in the patient’s chart. If a query is made verbally, then the answer must be in writing and placed in the patient’s chart.
Your first query should be: Why was an evaluation and management (E/M) code billed? The information in the documentation does not provide enough support for a separate and/or identifiable reason for the E/M visit. Keep in mind the relative value units assigned to CPT codes for infusion include an inherent E/M component. Often, before most procedures are performed, the attending provider evaluates the patient to ensure the procedure can be done and is still the appropriate course of management. In other words, the E/M service must meet the requirements of the service and meet medical necessity.
Your second query should be: What is the patient’s weight? The dosing indication for infliximab is based on the patient’s weight. The dosing instruction is 3 mg/kg IV at Weeks 0, 2 and 6, and then every eight weeks. If an incomplete response is documented, the dose may be increased to 10 mg/kg or the dosing frequency may be increased to every four weeks. To determine the correct dosing, the weight of the patient should be converted to kilograms and multiplied by 3 mg of the medication. The documentation should also state what phase the patient is in their treatment.
Your third query should be: What is the exact time the infusion was started and the time it was completed? It is insufficient to simply record the total time of the infusion because the time is counted only from the first drip of the medication to the last drip.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at email@example.com or call 404-633-3777 x820.