Answer
CPT: 96413, 96415 x1, J1745 x 19 J1745-JW* x 1
Diagnosis: ICD-9 714.0 and ICD-10 M05.09
Rationale: The 2014 AMA Current Procedural Terminology manual states, “Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents.”
The infliximab infusion is a highly complex biologic code, which should be coded to CPT 96413 for the first hour of infusion, and CPT 96415 is used to code each additional hour of the infusion up to eight hours. Because the patient’s infliximab was infused over two hours and 10 minutes, it is coded with both 96413 and 96415×1. Note that in order for an additional hour to be billed, the infusion would have to be at least 31 minutes into the next hour. The time does not start for the infusion until the actual medication is started, not when the IV port is inserted.
J1745 is the drug HCPCS code for infliximab 10 mg, of which the patient received 200 mg. The correct way to code for the drug is J1745 x 20 (20 x 10 = 200 mg). According to the CMS infliximab medical policy for the diagnosis of RA, the dosage allowed is 3 mg/kg IV. If the patient currently weighs 135 lbs., that means she would be allowed 61.24 kg x 3, which equals 183.72 mg of infliximab that should be used. Because infliximab comes in 10 mg vials, the dosage would be rounded up to 19 vials. The other 10 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 clearly document why and how much drug was wasted.
