Coding & Billing
REMICADE® (infliximab)
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Downloadable Forms
- Benefits Investigation & Enrollment Form
A way to find out if REMICADE® 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 REMICADE® 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 REMICADE® 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 REMICADE® is medically necessary for your patient. - Patient Account Overview
- Patient Affordability OptionsDiscover options that can make REMICADE® 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 REMICADE®. - Savings Program Overview
Eligible patients using commercial or private insurance can save on out-of-pocket costs for REMICADE®. - Savings Program Patient Enrollment Form
Fax or mail this completed form to enroll your patient in the Savings Program for REMICADE®. - Savings Program Rebate FormA form the patient can submit if the pharmacy isn’t able to process the Janssen CarePath Savings Program card.
- Specialty Distributors
- 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 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:
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96413 |
Chemotherapy administration, intravenous infusion technique, up to one hour, single or initial substance |
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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 REMICADE®.
Coverage
You should know that there is a demonstrated history of paid claims for REMICADE® 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 REMICADE®. Copies of coverage policies are available on your regional Medicare Administrative Contractor (MAC) website.
You can bill most payers electronically for REMICADE® 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 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 Janssen CarePath
Janssen CarePath provides information and assistance regarding coding, coverage, and claims process related to REMICADE®. 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.