Wednesday, 6 September 2017

CODING FOR REMICADE

Codes for Drug Administration

Drug administration services are reported on claim forms in both the physician office (CMS- 1500) and hospital outpatient (CMS-1450) sites of care using the CPT® coding system. The CPT® codes most commonly associated with the administration of REMICADE® are:

  • 96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug, and
 • 96415 - Each additional hour (Use 96415 in conjunction with 96413; report 96415 for infusion intervals of greater than 30 minutes beyond 1 hour increments.) Alternatively, some payers may require the use of CPT® codes:
 • 96365 - Intravenous infusion for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, and
 • 96366 - Each additional hour (List separately in addition to code for primary procedure; report 9636

Payer policies for codes used to describe infusion services may vary. Consult your payers for policies regarding use of 96413 and 96415 or 96365 and 96366. For additional assistance, contact Janssen CarePath at https://www.JansenCarePath.com/hcp/remicade or 877-CarePath (877-227-3728).

SAMPLE CLAIM FORMS

The Form CMS-1500 is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from suppliers and non-institutional providers that qualify for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It has also been adopted by the TRICARE Program. For detailed guidance on completing the CMS-1500 items, please see the Medicare Claims Processing Manual, Pub. 100-04, Chapter 26, available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf 


The 837P (Professional) is the standard format used by healthcare professionals and suppliers to transmit healthcare claims electronically. The American National Standards Institute (ANSI) Accredited Standards Committee (ASC) X12N 837P (Professional) Version 5010A1 is the current electronic claim version. Data elements in the CMS uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. 
For more information on electronic claims, please see the CMS website at:

https://www.cms.gov/medicare/billing/electronicbillingeditrans/healthcareclaims.html 

To view a crosswalk between the electronic and hard copy claim form, please see: http://www.nucc.org/images/stories/PDF/1500_form_map_to_837p_5010_v2-0_112011.pdf 

The Form CMS-1450, also known as the UB-04, is a uniform institutional provider bill suitable for use in billing multiple third-party payers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from hospitals, including HOPDs. Because it serves many payers, a particular payer may not need some data elements. For detailed guidance on completing the CMS-1450 items, please see the Medicare Claims Processing Manual, Pub. 100-04, Chapter 25, available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c25.pdf

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