Rheumatoid arthritis (RA) usually requires a lifelong treatment regimen that may include medications, physical therapy, exercise, education and possibly surgery. Early treatment for rheumatoid arthritis can delay joint destruction. There are a number of medications that clinicians have at their disposal when treating this disease. Accordingly, let us take a closer look at the current codes for some of these medications.

Clinicians may prescribe disease-modifying antirheumatic drugs (DMARDs) after less potent drugs prove to be ineffective for a patient. Nurse practitioners, physician assistants and other clinicians use DMARDs to treat rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and lupus. Commonly used DMARDs in rheumatology include gold compounds, methotrexate, leflunomide (Arava, Sanofi-Aventis), sulfasalazine and hydroxychloroquine.



Clinicians can administer gold by injection or it can be given orally. The drug administration CPT-4 code for this procedure is as follows:
• 90772 — Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.1
• The HCPCS code is J1600.

When one administers gold as an injection, there can be side effects such as itchy rashes and mouth ulcers. However, these will disappear when the injection treatments are discontinued. There are reportedly fewer side effects with the oral formulation as diarrhea is the most common side effect.

Insights On Coding For Methotrexate
Methotrexate is FDA approved for the treatment of rheumatoid arthritis. In the past, clinicians would only prescribe methotrexate after patients had failed other DMARD medications. However, it is now standard practice to use methotrexate as a first line treatment for patients who have moderate to severe forms of rheumatoid arthritis. One can administer methotrexate via injection or it can be taken orally.

The drug administration CPT-4 code for methotrexate is 96401 — Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.1 The HCPCS for this drug is as follows: J9250 — methotrexate sodium, 5 mg; J9260 — methotrexate sodium, 50 mg; or J8610 — methotrexate, oral, 2.5 mg.

When considering methotrexate, one should be wary of liver disease and interstitial pneumonitis. It is recommended that all patients receive a tuberculosis test before one prescribes methotrexate.

Other DMARDs Clinicians May Consider
Clinicians may utilize leflunomide in combination with other drugs such as methotrexate. Leflunomide impedes the development of deoxyribonucleic acid, which is important in combating the autoimmune disorder of RA. The patient may not feel the full effect from the medication for several weeks. Clinicians usually prescribe leflunomide as a 10 or 20 mg tablet once a day but some patients may not be able to tolerate the higher dosage.

Hydroxychloroquine is another DMARD. Hydroxychloroquine was originally used to prevent and treat malaria. Presently, clinicians use it to treat RA, juvenile rheumatoid arthritis and lupus. Clinicians may prescribe hydroxychloroquine as a 200 mg tablet twice a day or at 400 mg once a day. Patients may start to improve in one to two months but may not feel the full effect for six months or more.

One may utilize sulfasalazine to treat RA as well as ulcerative colitis. The dose is usually 2 g/day but can go up to 6 g/day.

What You Should Know About Coding For Biologic Response Modifiers
Clinicians may prescribe biologic response modifiers for people with RA who did not have success with other therapies. In some cases, practitioners combine biologic response modifiers with standard DMARDS. For example, clinicians may combine methotrexate with infliximab (Remicade, Centocor).

Adalimumab (Humira, Abbott), etanercept (Enbrel, Amgen/Wyeth) and infliximab are three commonly used biologic response modifiers in the treatment of RA.

One would administer adalimumab and etanercept by injection, and administer infliximab via infusion. Infliximab treatments can be done in the physician’s office by nurse practitioners or physician assistants. It can also be given in a hospital setting. These drugs are also known as anti-TNF drugs because they block a cytokine called tumor necrosis factor-alpha (TNF-a). The CPT-4 codes for this drug administration are as follows:

• 96413 — Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug, and
• 96415 — each additional hour, 1 to 8 hours (list separately in addition to code for primary procedure).1
The HCPCS code for infliximab is J1745.

Clinicians should keep in mind that adalimumab and etanercept are considered self-injectable drugs by the Centers for Medicare and Medicaid Services (CMS). Accordingly, one would not receive Medicare or Medicaid reimbursement for administration of these drugs in the office setting.

Melesia R. Collins, CPC

Other drugs like azathioprine (Imuran) and cyclophosphamide (Cytoxan) reportedly suppress the immune system. The HCPCS codes for azathioprine are as follows: J7500 — azathioprine, oral 50 mg; and J7501 — azathioprine, parenteral, 100 mg. However, these medications are associated with toxic side effects and clinicians usually reserve these for severe cases of RA.

What About Coding For Rituximab And Abatacept?
Recently, the FDA has approved rituximab (Rituxan, Genentech) and abatacept (Orencia, Bristol-Myers Squibb) for the treatment of rheumatoid arthritis (RA).

One may prescribe rituximab along with methotrexate to patients who have failed one or more anti-TNF drugs. Clinicians can administer rituximab via IV infusion. For rituximab, clinicians would utilize the drug administration CPT-4 code 96413. The HCPCS code is J9310.

In December 2005, abatacept was approved to treat RA. Clinicians would also administer this drug by IV infusion and the drug administration CPT-4 code to bill for this service is 96413.

Keep in mind that abatacept does not have a permanent HCPCS code to date. Accordingly, nurse practitioners and physician assistants will have to code this as an unclassified biologic HCPCS code, which is J3590. Since this HCPCS code is unlisted, one should also code a national drug code number (NDC) on the claim along with the amount of drug that you have used for the patient. One can obtain the NDC number from the manufacturer of the drug.

A permanent HCPCS code will be available in January for abatacept.

A Guide To Coding For Osteoporosis Medications
Alendronate (Fosamax, Merck) and risedronate (Actonel, Proctor and Gamble Pharmaceuticals and Sanofi-Aventis) are oral medications clinicians can prescribe for the management of osteoporosis. These antiresorptive medications interfere with the breakdown of bone from the loss of bone mineral density that occurs in osteoporosis. The dose is usually 70 mg once a week for alendronate and 35 mg once a week for risedronate. The most common side effect is gastrointestinal upset.

Another option is the injectable parathyroid hormone teriparatide (Forteo), which one can prescribe at 20 mg subcutaneously with up to two years of use. The main side effects include osteosarcoma in animal studies, hypotension and dizziness.

Antanya A. Chung, CPC

One may also prescribe raloxifene (Evista, Eli Lilly and Company) at 60 mg a day. Its main side effects are deep venous thrombosis or pulmonary embolism. Clinicians may also consider calcitonin-salmon (Miacalcin, Novartis Pharmaceuticals), which is a daily nose spray for treating osteoporosis.

Lastly, ibandronate (Boniva, Roche) was approved this year for the treatment of postmenopausal osteoporosis. A nurse practitioner or a physician assistant can administer this drug once every three months. The drug administration CPT-4 code for this procedure is 90774 — intravenous push, single substance/drug.1
The HCPCS code for ibandronate is also unlisted so clinicians should use the unclassified HCPCS code J3490 for now. One should also code the NDC number with the bill. A permanent HCPCS code will be available in January for ibandronate.

In Conclusion
Of course, this is just a sampling of the available drugs that clinicians can prescribe for rheumatoid arthritis, osteoporosis and other autoimmune diseases. Hopefully, this information, along with the appropriate coding, can facilitate error-free claims and timely reimbursement as you strive to achieve favorable treatment outcomes for your patients.