CPT: 99214-25, 96413, 96375, 96361-59, J1745 x 4 J1745 JW* x 36, J1200 x1
ICD-10: M45.09, T50.995A, R06.02, E66.3, Z68.2
Rationale
Modifier 25 is appropriate to use because it indicates the patient received a significant, separately identifiable E/M service on the same day as the infliximab infusion. This E/M service entailed the following:
- History—Detailed;
- Examination—Detailed; and
- Medical decision making—Moderate complexity.
The infliximab is coded with CPT 96413 for the first hour of the infusion and would be the only procedural code because the infusion was stopped 22 minutes into the infusion. The initial hour can be billed, as long as it is 16 minutes or more. Keep in mind, the actual time does not start for the infusion until the medication begins to drip, not when the IV port is inserted.
Also, the patient had a push of diphenhydramine prophylactically prior to the infusion, but only one initial code can be used for the drug administration series, so this procedure should be coded as an additional push. Even if this procedure is performed first, the main procedure, which is the infusion, is the initial code. The infusion of saline can be billed as long as it is used as an avenue to flush medication due to an adverse drug reaction.
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 400 mg of infliximab, the correct way to code this is J1745 x 40 (40 x 10 = 400 mg); 36 units were wasted, so 360 mg would have to be documented as drug wastage and coded with a modifier JW to indicate drug wastage.
As of January 2017, Medicare requires the use of the JW modifier. There must be documentation of why the drug was wasted and how much of the drug was wasted. Some carriers will require that drug wastage be billed on a second line, with the JW modifier on the line with the wastage, and some carriers require that only one line is billed, with the JW on the one line. Practices will have to verify the acceptable format with their Medicare carrier. Many private carriers do require the use of the JW modifier with the wasted drug listed on a separate line. The medical record must still document why and how much drug was wasted.