Coding & Billing
Infliximab
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Downloadable Forms
- Benefits Investigation & Enrollment Form
A way to find out if Infliximab is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies. - Benefits Investigation & Prescription Form for GastroenterologyA way to find out if Infliximab is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies.
- Benefits Investigation Form for Janssen IV
A way to find out if Infliximab is covered by the patient's insurance plan, including requirements for coverage or prior authorization, any out-of-pocket costs, and approved pharmacies. - Billing Guide
- Business Associate Agreement
Complete a Business Associate Agreement for your practice only once. No individual patient authorizations are required. - Janssen CarePath Resource GuideA comprehensive summary of support tools for your office to help patients start and stay on treatment.
- Letter of Exception
A template that you can fill out and submit to a patient’s health insurance provider asking them to cover a medication that is not on formulary. - Letter of Medical Necessity
A template that you can fill out and submit to a patient’s health insurance provider. You may use it to explain why Infliximab is medically necessary for your patient. - Patient Account Overview
- Patient Affordability OptionsDiscover options that can make Infliximab more affordable for your patients.
- Patient Authorization FormIndividual patient form for offices without a Business Associate Agreement.
Patient Authorization Form (en español) - Patient Authorization Form (en español)Individual patient form for offices without a Business Associate Agreement.
- Savings Program Assignment of Benefits FormA form the patient can submit that allows Janssen CarePath Savings Program to reimburse the provider directly.
- Savings Program EOB Clarification Form
Use this form when the Explanation of Benefits (EOB) statement does not indicate that the patient received Infliximab. - Savings Program Overview
Eligible patients using commercial or private insurance can save on out-of-pocket costs for Infliximab. - Savings Program Patient Enrollment Form
Fax or mail this completed form to enroll your patient in the Savings Program for Infliximab. - Savings Program Rebate FormA form the patient can submit if the pharmacy isn’t able to process the Savings Program card or for a medical benefit rebate.
- Verification of Benefits Guide (Medical)
A guide to understanding the Verification of Benefits for your patient’s medical benefits. - Verification of Benefits Guide (Pharmacy)
A guide to understanding the Verification of Benefits for your patient’s pharmacy benefits.
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Coding & Billing
Coding
The product-specific HCPCS code for Infliximab 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 Infliximab 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 Infliximab 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 Infliximab. The descriptions for the most commonly used codes to describe first and subsequent hours of administration of Infliximab are:
|
96413 |
Chemotherapy administration, intravenous infusion technique, up to one hour, single or initial substance |
|
96415 |
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 Janssen CarePath for assistance at 877-CarePath (877-227-3728).
Be sure to consult your payer for specific coding requirements for Infliximab.
Coverage
You should know that there is a demonstrated history of paid claims for Infliximab for all payer types, 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 Infliximab. Copies of coverage policies are available on your regional Medicare Administrative Contractor (MAC) website.
You can bill most payers electronically for Infliximab and its associated services.
Documentation of Services
Keep the following tips in mind to help ensure that your documentation is thorough and accurate:
- When billing for evaluation and management (E&M) services in addition to administration of Infliximab , 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 Janssen CarePath
Janssen CarePath provides information and assistance regarding coding, coverage, and claims process related to Infliximab. In addition, we can also investigate specialty pharmacies that may be available to simplify product procurement and billing for healthcare providers.
If you have questions, please call a Janssen CarePath Care Coordinator at 877-CarePath (877-227-3728), Monday-Friday, 8:00 AM to 8:00 PM ET. Multilingual phone support is available.