ICD-10: M05.09
This encounter is coded as 99213 because:
- History—The history of present illness is extended. The review of systems is detailed, and two of the three past, family, social history were documented, which makes the history level detailed.
- Exam—There are four systems examined, which makes the exam level expanded problem focused.
- Medical decision making—The diagnosis is an established problem that is worsening, with a lab review and prescription drug management; the medical decision making is low complexity.
Coding Rationale
Infliximab is considered a chemotherapy infusion, and CPT code 96413 is used for the first hour of an infusion and 96415 is used to code each additional hour, up to eight hours. Because the patient’s infliximab was infused over two hours and 12 minutes, it is coded with both CPT codes 96413 and 96415×1. In order to bill for an additional hour, the infusion would have to last at least 31 minutes into the next hour. Keep in mind that time does not start being counted for the infusion until the actual medication begins to drip, not when the IV port is inserted.
The HCPCS drug code for infliximab 10 mg is J1745, but this 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).
*In the Balanced Budget Act of 1997, Congress ordered that reimbursement for many of the services provided to Medicare beneficiaries residing in a skilled nursing facility be included in a bundled prospective payment made through Part A Medicare Administrative Contractor (MAC). This is considered to be consolidated billing. Only one payment will be reimbursed for all services for the patient while they reside in the SNF, unless the service is from the excluded list. Below is a list of services that are reimbursed separately under the Medicare Part B fee-for-service schedule for patients who reside in an SNF:
- Physician’s professional services
- Evaluation and management
- Professional component of radiology
- Certain dialysis-related services, including covered ambulance transportation to obtain the dialysis services
- Certain ambulance services, including ambulance services that transport the beneficiary to the SNF initially, ambulance services that transport the beneficiary from the SNF at the end of the stay (other than in situations involving transfer to another SNF), and roundtrip ambulance services furnished during the stay that transport the beneficiary off-site temporarily in order to receive dialysis, or to receive certain types of intensive or emergency outpatient hospital services
- Erythropoietin for certain dialysis patients
- Certain chemotherapy drugs
- Cancer drugs
- Certain chemotherapy administration services
- Radioisotope services
- Customized prosthetic devices
Because the patient resides in an SNF, Medicare will not reimburse the provider directly for the cost of the infliximab. The provider will need to negotiate payment with the SNF prior to providing the drug. Otherwise, the practice will have no control as to how much, if any, reimbursement will be provided to the practice after services are rendered. If it has been determined that Medicare is the primary payer, it is always best practice for the front office staff or schedulers to verify if the patient has been an inpatient in any hospital or SNF, including swing bed stays, during the past 60 days prior to providing infusion services.