Coverage policies may vary by insurer or even between plans offered by the same insurer.
This information is presented for informational purposes only and is not intended to provide reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are complex and are updated frequently. While we have made an effort to be current, the information may not be as current or comprehensive when you view it. Please consult with your counsel or reimbursement specialist for any reimbursement or billing questions.
Overview of Reimbursement for REMICADE® (infliximab)
This overview outlines the key points you need to know about reimbursement for REMICADE®. It includes details about coding and coverage for REMICADE® and its administration, important information about documentation of services, and reimbursement support services for REMICADE® for your practice.
The product-specific HCPCS code for REMICADE® is J1745, infliximab, 10 mg. It is important to note that this code represents 1/10th of a vial. You should be sure to bill 10 units of J1745 on the claim form when indicating that a single 100-mg vial of REMICADE® was used.
1 vial = 10 units
2 vials = 20 units
3 vials = 30 units
Medicare uses CPT codes 96413 and 96415 to describe the first and subsequent hours, respectively, of the infusion procedure associated with therapy with REMICADE® in the physician office setting. Commercial payers may use these codes or alternate codes 96365 and 96366.
Hospital claims should use CPT codes 96413 and 96415 to describe administration of REMICADE®. The descriptions for the most commonly used codes to describe first and subsequent hours of administration of REMICADE® are:
Chemotherapy administration, intravenous infusion technique, up to one hour, single or initial substance
Chemotherapy administration, intravenous infusion technique, each additional hour, single or initial substance (list separately in addition to code 96413 for initial hour of infusion services)
Non-Medicare payer policies regarding the use of 96413 and 96415 may vary. Alternatively, some may prefer use of CPT codes 96365 (IV infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) and 96366 (IV infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; each additional hour). (List separately in addition to code for primary procedure.) Please consult your local payer for specific coding policies, or call AccessOne® for assistance at 1-ACCESS-1 (1-888-222-3771).
Be sure to consult your payer for specific coding requirements for REMICADE®.
You should know that there is a demonstrated history of paid claims for REMICADE® for all payers, including Medicare, Medicaid, and commercial plans. Coverage varies by carrier and individual patient case.
There are comprehensive, published Medicare Part A and Part B coverage policies specific to REMICADE®. Copies of coverage policies are available on your regional Medicare Administrative Contractor (MAC) website, and these can be found in the Billing and Reimbursement section of this website.
You can bill most payers electronically for REMICADE® and its associated services.
Documentation of Services
Keep the following tips in mind to ensure that your documentation is thorough and accurate:
- When billing for evaluation and management (E&M) services in addition to administration of REMICADE®, be sure that the E&M services are separately identifiable and medically necessary and that justification is noted in the patient record
- Correct use of modifiers is important—make sure modifiers are accurate and appropriately reflected in the patient record
- Always verify payer rules for the billing of E&M codes
Reimbursement Support Through AccessOne®
AccessOne® provides information and assistance regarding coding, coverage, and claim submissions related to REMICADE® (infliximab). In addition, AccessOne® can also investigate specialty pharmacy options that may be available to simplify product procurement and billing for health care providers. Finally, AccessOne® can provide reimbursement information and support directly to patients.
AccessOne® is available at 1-ACCESS-1 (1-888-222-3771), Monday-Friday, 8 AM-8 PM ET.
AccessOne® can assist you with the following:
- Benefits investigation, to determine patient-specific benefits for REMICADE®
- Alternate coverage research for patients requiring coverage or additional coverage for REMICADE®
- Requirements for prior authorization process
- Assistance with the appeal process for administrative denials
- Infusion site location assistance through www.2infuse.com
- Personalized care coordination including benefits explanation to your patients
Upon patient request:
- Appointment reminder calls and follow-up calls
- Patient education materials, providing disease-state information and infusion education for all approved indications for REMICADE®
Reference documents contain important information you need to know about the reimbursement process for REMICADE®.
This guide is intended to help healthcare providers and billing staff understand third-party reimbursement for infusible drugs and the services by which they are administered. Specifically, this guide presents general coverage, coding and payment information relevant to the sites of care in which infusible drugs are administered, and references resources for additional help.
Sample Letter of Medical Necessity
Sample letter that you can submit with either the initial claim to support the medical necessity of treatment with REMICADE® for your patient or submit it to support the medical necessity of treatment with REMICADE® when requesting reconsideration of a denied claim. Click here for the sample letter.
CPT copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.