How You Should Document and Code MS and the use of Gilenya

On March 8th, 2011, posted in: Industry News, Tips by

FDA regulations direct providers to monitor a patient for six hours after the initial dose of Gilenya because of potential bradycardia or AV block. And, because it is newly approved, there isn’t a specific code for this service.

For now, you will report the appropriate level E/M code (99212-99215 – documentation dependent) and the prolonged visit code 99354 for the first hour, then 99355 for each addition 30 minutes. Your documentation must clearly indicate the time units and any exam you performed during this time period.

Because Gilenya is an oral medication, payers consider it ‘self-administered’; therefore will not reimburse you for providing the medication. Some practices write scripts and have the patient bring the medication to the office; others will refer the patient to an infusion center or provide the service in an outpatient hospital setting if their office is not prepared to deal with the potential side effects.