Answer
99214-25. 96413, 96375, 96361-59, J1745 x 3 J1745 JW* x 17, J1200 x1
Diagnosis ICD-9: 714.0, 995.27, E947.8
ICD-10: M05.09, T50.995A
Modifier -25 is used to indicate the patient received a significant, separately identifiable E/M service on the same day as her infliximab infusion. This E/M service entailed:
- The history is expanded, problem focused;
- The examination is detailed; and
- The medical decision making is of moderate complexity.
The infliximab is a chemotherapy infusion and should be coded with CPT code 96413 for the first hour of the infusion. The patient had a push of diphenhydramine as a prophylactic prior to the infusion. Only one initial code can be used for the drug administration. This could be coded as an additional push. Even if this code was performed first, it is permissible to code the main code, which was the infusion, as the initial code. Because the patient’s infliximab infusion was stopped after 22 minutes, the only code for the infusion that should be coded is 96413. The initial part of the first hour can be billed, as long as it is 16 minutes or more. Keep in mind that the time does not start for the infusion until the actual medication is started, not when the IV port is inserted. The infusion of saline can be billed as long as it is used as an avenue to flush out the medication from the adverse drug reaction. This would be coded as the additional hour of hydration because there can only be one initial hour of drug administration code per session. Modifier -59 should be used to identify the hydration as distinct and separate: “… not normally reported together, but are appropriate under the circumstances.” Documentation should be noted in the patient’s record to support the different procedure that is not ordinarily encountered or performed on the same day.
J1745 is the drug HCPCS code for infliximab 10 mg, but the drug is sold as 100 mg of lyophilized infliximab in a 20 mL vial. Because the patient received 200 mg of infliximab, the correct way to code this is J1745 x 20 (20 x 10 = 200 mg). Seventeen units were wasted, so 170 mg would have to be documented as drug wastage and coded with a modifier JW to indicate drug wastage.
*Currently, Medicare does not require the use of the JW modifier, but still requires documentation in the medical record of any drug wastage. Many private carriers do require the use of the JW modifier with the wasted drug listed on a separate line, and the medical record must be documented concerning why and how much drug was wasted.