Rheumatology Coding Corner Answer: Billing for an Inflectra Infusion

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CPT codes: 96413, 96415, 96375, Q5103x20, J1200
ICD-10: M07.9

Coding Rationale

hxdbzxy; Anna Jurkovska / shutterstock.com

This procedure is billed with CPT code 96413 for the initial hour of the intravenous infusion and CPT code 96415 for each additional hour. The patient was given 50 mg of diphenhydramine prior to the infusion to prevent reactions and should be billed with CPT 96375, because only one initial drug administration code can be billed on the same date of service.

Based on guidance from the Centers for Medicare & Medicaid Services (CMS), effective April 1, 2018, HCPCS code Q5103 should be used when submitting claims for infliximab-dyyb, and the NDC is 00069=0809-xx. Bill for the units of Inflectra at 10 mg X 20 (two vials = 200 mg).

Keep in mind, an evaluation and management (E/M) service is not billed with this visit because there is no medical necessity according to the documentation guidelines to code for an E/M visit. The service would not be separately reimbursed, because there is no significant, separately identifiable work performed by the provider.

For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.