If you’re shaky on how to report Gilenya (fingolimod) as a first-line treatment for relapsing forms of multiple sclerosis (MS, ICD-9 code 340), you’re not alone. Gilenya questions have circulated ever since the FDA approved the drug in September 2010. Check our answers to three of the most common questions coders have so you’ll be ready when your neurologist offers the initial treatment dose to patients.
1. What’s the Best HCPCS Code?
“Gilenya is newly approved by the FDA, so there’s no HCPCS code for the drug,” says Catherine Nolin, CPC, a specialty based coder with Central Main Medical Center in Lewiston.
Result: Your only HCPCS choice currently is J3490 (Unclassified drugs), but verify details before submitting the code. Physicians sometimes write a prescription so patients can obtain and purchase the medication from a local or specialty pharmacy before coming to the office for administration. In those situations, your office should not submit any J code for drug reimbursement.
2. How Should We Code for Monitoring?
When beginning treatment with Gilenya, the FDA recommends observing the patient for a period of six hours. After taking the initial dose of the oral medication, the patient is monitored for signs and symptoms of bradycardia. Your neurologist needs to be available in the office to manage any post-dose arrhythmia-related side effects.
Dilemma: Physicians don’t normally track the patient’s status following the administration – a nurse does. The only CPT E/M code allowed for nurse care is CPT 99211 (Office or other outpatient visit for the evaluation and management of an established patient,...
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