CPT codes: 96413, 96415, 96375, J1745x30, J1200x1
Diagnosis ICD-10: M05.79
With the total infusion time of two hours and 13 minutes, CPT code 96413 is used to code for the first hour of the infusion and 96415 for the additional hour. The infusion would have to be 31 minutes into the next hour to consider an additional unit. The patient had a push of diphenhydramine prophylactically intravenously prior to the infusion and should be coded with CPT 96375. Note: The push is coded as an add-on code because only one initial code can be used when billing for the drug administration. Even though the push is performed first, according to coding guidelines it is permissible to code the main code, which was the infusion, as the initial code.
The Healthcare Common Procedure Code System J1745 is the drug code for infliximab 10 mg, but the drug comes as 100 mg of lyophilized infliximab vials. Because the patient received 300 mg of infliximab, the correct way to code this is J1745x30 (30 x 10 = 300 mg). The dose can be from 3 mg/kg IV up to 10 mg/kg if lower doses do not improve control of the patient’s rheumatoid arthritis.
Caution: No medical necessity or significant separate reason exists to code for an E/M visit, and this note is vulnerable to audit and could be denied for lack of documentation to support the medical necessity of the choice of dose, and also for lack of documentation of patient improvement. Recently, an increase in Zone Program Integrity Contractor (ZPIC) audits based on not meeting the standards in documentation for infusion claims (in particular for infliximab) has been noted. If a practice receives a request for notes from a ZPIC auditor, the practice should be aware that ZPIC has a suspicion of fraud. It does not mean the practice is committing fraud, but the audit requests should be taken seriously. It should be emphasized that, as with any audit, all supporting data should be sent at the same time; some auditor contractors will only give you one chance to submit all supporting evidence.
What is lacking in this note is evidence of the patient’s improvement as a reason for continuing the treatment with infliximab infusions. Many rheumatologists assume that simply stating the patient has no more joint damage and can continue to work and have a normal life is proof of patient improvement. However, payers are looking for clinical data, such as the ACR guidelines on treating RA.