Understanding alternative therapy billing and coding in TRD

Steven Levine, MD: We discuss some of the important considerations in benefit design and highlight some of the complexities of the system. These complexities extend to billing and coding. Sometimes navigating these complexities is reason for patients who are already struggling to give up along the way and not get the care they need. These complexities can also extend to suppliers and billing managers. Ms. Jardine, could you perhaps speak to that and some of the challenges you see in that regard?

Carrie Jardine: Absolutely. It is important to understand payer guidelines and policies to ensure that the treatments that the provider and patient have determined to be best are reimbursed in a timely manner. Specifically, for a newer treatment like Spravato or esketamine, it was such a different type of drug in its delivery and observation period that there was a lot of education that needed to be done from side of the supplier’s office for the management of payers’ claims. and vendor representatives.

When you try to get information about benefits and eligibility from provider representatives who are used to dealing with basic benefits, and you start asking for more specific things like medications and periods of observation, you can give them codes. You need to make sure you have the correct codes based on the policies they have. Often vendor representatives are confused and may not have the right information and tools in front of them to give the practice or patient the correct information for things like out-of-pocket expenses.

Knowing which codes are going to be recognized by which payers is very important for benefit and reimbursement investigations. Looking at something like Spravato or esketamine, there are many different ways that can be coded and recognized by a payer. It also has to do with whether you’re buying and billing, whether it’s a Medicare patient, whether you need to use a J code or an S code for pharmacy benefits, or whether you need to use the G code which CMS [Centers for Medicare & Medicaid Services] created as an all-inclusive code. Knowing which payers recognize this is difficult to understand. Knowing what applies to which patient can also be difficult to navigate.

Steven Levine, MD: In all of this, what insights can you provide on how vendors, billing managers, and revenue cycle managers are navigating and understanding the appropriate codes to use with which payers and under what circumstances?

Carrie Jardine: Familiarize yourself with your payers’ websites. The information is generally available. Some payers don’t make it easy to find, but check out those websites. If you happen to have a vendor representative you can get in touch with, these are great resources to help point you in the right directions. They may not be able to tell you directly due to different legalities, they can’t help you with coding, but they can definitely point you in the right direction to find these policies and what codes are recognized and applicable. Sometimes you have to nudge the vendor reps you call to the right area to make sure you’re getting the right benefits for the patient.

Steven Levine, MD: You mentioned earlier that there are potentially separate codes for drug versus delivery and monitoring. Sometimes they are grouped together and covered by a more comprehensive G-code. In what you describe about how to make sure you code and submit claims correctly, are there other ways to ensure timely access and reimbursement for the components of intranasal esketamine?

Carrie Jardine: Understand your payers and their structures, the difference between drug and medical benefits, whether you will buy and bill or go through a specialty pharmacy, and understand if you have a Medicare or Medicare Advantage patient that there is the all-inclusive G- code that can be billed for the medication, observation period or any type of office visit made that day.

Another thing to watch out for are your contracts as not all contracts are the same or have the codes you need. When we started negotiating contracts, there were payers leaving all types of TMS [transcranial magnetic stimulation] codes outside of our fee schedule, as well as Spravato codes, such as observation code 99417. please add them to our contracts. .” Otherwise, you will not be paid for these services if they are not included in your contract.

Patricia Ares-Romero, MD, FASAM: This is so important because we also encountered this problem. You must ensure that these codes or services are included in the contracts. Whoever does your income cycle, be sure to do it. Its very important. The other thing I want to add is that you can use certain services like CarePath—I think they’ve changed their name now—because it’s important to distinguish whether the patient has a medical benefit or a benefit pharmaceutical as part of that as well. I wanted to add that to the conversation.

Transcripts edited for clarity.

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