Answer: 99213-25, 96413, 96415 x 1, 96375, J1200 x1, J1745 x20
This infusion procedure is billed with a level-three evaluation and management (E/M) service with modifier -25 to indicate a significant, separately identifiable E/M service was performed on the same day as a procedure. The E/M service entailed:
- An expanded problem-focused history;
- An expanded problem-focused examination; and
- A medical decision making of low complexity.
Infliximab is considered a chemotherapy infusion and is reported with CPT code 96413 for the first hour of the infusion; 96415 is used to code each additional hour of the chemotherapy infusion up to eight hours, because the infusion was given for two hours and 10 minutes. Time starts for the infusion when the medication starts to drip, not when the IV port is inserted. Although the diphenhydramine was given to the patient prior to the infusion, coding guidelines indicate that the primary procedure should be billed first, followed by any subsequent code.
The 2006 CMS Transmittal 968 Change Request 5028 on coding revision for “Chemotherapy Administration and Nonchemotherapy Injection and Infusion Coding Policy” indicates:
When administering multiple infusions, injections or combinations, the physician should report only one “initial” service code unless protocol requires that two separate IV sites must be used. The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code should be reported. For example, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code.
HCPCS code J1745 is reported for the infliximab 10 mg. Because the patient received 200 mg of infliximab, the correct way to code this is J1745x20 (20 x 10 = 200 mg).