Physicians can help their patients get the treatments they prescribe by providing their staff with the prior authorization information they need to properly complete the necessary forms. As more and more biologics for psoriasis are coming to the market, we are facing new challenges with the prior authorization process. Billing and Coding Injectables Billing and coding issues with injectables are quite complicated. We can classify billing of injectables into two major categories: prescription or buy and bill. Buy and Bill First, let’s take a look at the buy and bill process. J code — We must use the J code for in-office injectables or infusable biologics; the two currently available are alefacept 0.5mg J0215 and infliximab J1745 10mg IV. These codes must be billed in units. For example, alefacept, is given 15 mg per week, so it is billed as J0215 X 30 units. Administration code — In addition to the J code, an administration code is allowed. Therefore, for the alefacept IM injection, code 96372 can be used; for the infliximab IV infusion, 96365 can be used. (See table on next page.) Prescription While this may make writing a prescription for home administration look easy, securing prior authorization for any of these biologic prescriptions is neither simple nor easy. However, despite the burden prescribing biologics places on our office staff, the difference these drugs can make in the quality of psoriasis patients’ lives makes our efforts worthwhile, so I will continue to prescribe them. AVOIDING APPEALS AND DENIALS In reviewing appeals and denials for biologics from third-party payers, it is often the case that forms are simply either not answered fully nor correctly. We can make life a little easier for our staff if we physicians get involved in prior authorization forms. What You Must Include 1. Drug’s FDA indication — The FDA indication of the drug is very important. All biologics except infliximab are approved for moderate to severe plaque type psoriasis. Infiximab is approved for severe plaque type psoriasis. Therefore, if you mark guttate psoriasis or scalp psoriasis or mild plaque type psoriasis, your request will be immediately denied. If you mark moderate plaque type psoriasis then your request for infliximab will be denied. 2. Patient’s TB status — Most of the prior authorization forms ask if the patient has TB, so please document a negative PPD in the chart before you request the approval. This is good medical practice, and one that is necessary before starting patients on biologics. 3. Patient’s age — The patient’s age is important because none of these biologics are approved for patients under 18 years of age for psoriasis indication. While etanercept is approved for patients as young as 4 years of age for juvenile idiopathic arthritis, it is not likely to be approved for psoriasis in children. 4. Disease severity — Document that patient does not have moderate to severe (NYHA class III/IV) CHF if you prescribe TNF-a inhibitors. 5. Multiple sclerosis — Document that the patient does not have multiple sclerosis when prescribing TNF-a inhibitors. 6. Body surface area/sensitive areas — Be sure to document body surface area (BSA). Most third-party payers will allow 10% BSA or more. In addition, when BSA is less than 10%, but palms and soles or genitalia are involved, you should highlight that, as exceptions to the more than 10% BSA rule are made when sensitive areas are involved. 7. Earlier treatments — It is important to document either previous use of other systemic prescriptions or phototherapy or contraindications for any of those. If you have not previously written any prescriptions for a patient, you can request the records from previous dermatologists to show earlier treatment. What You Must Know About Contraindications and Prohibitions Prior to Prescribing 1. Cyclosporin — Even if the patient responded to cyclosporine, the FDA indication is only 1 year for psoriasis, so treatment cannot continue beyond that period. 2. Acitretin — Acitretin is certainly contraindicated in females of childbearing age. 3. Methotrexate — If the patient has had more than 1 or 2 years of cumulative methotrexate and refuses a liver biopsy, this may be a relative contraindication. Help Your Patient by Helping Your Staff Most of the requested information on PA forms is not that simple for our office staff. However, physicians can acquire this information as part of medical history and document it in the chart for quick transfer to the PA forms. Thus, we can save a lot of time and frustration for our office staff, which will lead to savings for us and faster approval for our psoriasis patients. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has been an investigator, speaker or an advisory board member for Genentech,Serono,Amgen,Centocor, and Astellas.
PRIOR AUTHORIZATION WITH BIOLOGICS
Physicians can help their patients get the treatments they prescribe by providing their staff with the prior authorization information they need to properly complete the necessary forms. As more and more biologics for psoriasis are coming to the market, we are facing new challenges with the prior authorization process. Billing and Coding Injectables Billing and coding issues with injectables are quite complicated. We can classify billing of injectables into two major categories: prescription or buy and bill. Buy and Bill First, let’s take a look at the buy and bill process. J code — We must use the J code for in-office injectables or infusable biologics; the two currently available are alefacept 0.5mg J0215 and infliximab J1745 10mg IV. These codes must be billed in units. For example, alefacept, is given 15 mg per week, so it is billed as J0215 X 30 units. Administration code — In addition to the J code, an administration code is allowed. Therefore, for the alefacept IM injection, code 96372 can be used; for the infliximab IV infusion, 96365 can be used. (See table on next page.) Prescription While this may make writing a prescription for home administration look easy, securing prior authorization for any of these biologic prescriptions is neither simple nor easy. However, despite the burden prescribing biologics places on our office staff, the difference these drugs can make in the quality of psoriasis patients’ lives makes our efforts worthwhile, so I will continue to prescribe them. AVOIDING APPEALS AND DENIALS In reviewing appeals and denials for biologics from third-party payers, it is often the case that forms are simply either not answered fully nor correctly. We can make life a little easier for our staff if we physicians get involved in prior authorization forms. What You Must Include 1. Drug’s FDA indication — The FDA indication of the drug is very important. All biologics except infliximab are approved for moderate to severe plaque type psoriasis. Infiximab is approved for severe plaque type psoriasis. Therefore, if you mark guttate psoriasis or scalp psoriasis or mild plaque type psoriasis, your request will be immediately denied. If you mark moderate plaque type psoriasis then your request for infliximab will be denied. 2. Patient’s TB status — Most of the prior authorization forms ask if the patient has TB, so please document a negative PPD in the chart before you request the approval. This is good medical practice, and one that is necessary before starting patients on biologics. 3. Patient’s age — The patient’s age is important because none of these biologics are approved for patients under 18 years of age for psoriasis indication. While etanercept is approved for patients as young as 4 years of age for juvenile idiopathic arthritis, it is not likely to be approved for psoriasis in children. 4. Disease severity — Document that patient does not have moderate to severe (NYHA class III/IV) CHF if you prescribe TNF-a inhibitors. 5. Multiple sclerosis — Document that the patient does not have multiple sclerosis when prescribing TNF-a inhibitors. 6. Body surface area/sensitive areas — Be sure to document body surface area (BSA). Most third-party payers will allow 10% BSA or more. In addition, when BSA is less than 10%, but palms and soles or genitalia are involved, you should highlight that, as exceptions to the more than 10% BSA rule are made when sensitive areas are involved. 7. Earlier treatments — It is important to document either previous use of other systemic prescriptions or phototherapy or contraindications for any of those. If you have not previously written any prescriptions for a patient, you can request the records from previous dermatologists to show earlier treatment. What You Must Know About Contraindications and Prohibitions Prior to Prescribing 1. Cyclosporin — Even if the patient responded to cyclosporine, the FDA indication is only 1 year for psoriasis, so treatment cannot continue beyond that period. 2. Acitretin — Acitretin is certainly contraindicated in females of childbearing age. 3. Methotrexate — If the patient has had more than 1 or 2 years of cumulative methotrexate and refuses a liver biopsy, this may be a relative contraindication. Help Your Patient by Helping Your Staff Most of the requested information on PA forms is not that simple for our office staff. However, physicians can acquire this information as part of medical history and document it in the chart for quick transfer to the PA forms. Thus, we can save a lot of time and frustration for our office staff, which will lead to savings for us and faster approval for our psoriasis patients. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has been an investigator, speaker or an advisory board member for Genentech,Serono,Amgen,Centocor, and Astellas.
Physicians can help their patients get the treatments they prescribe by providing their staff with the prior authorization information they need to properly complete the necessary forms. As more and more biologics for psoriasis are coming to the market, we are facing new challenges with the prior authorization process. Billing and Coding Injectables Billing and coding issues with injectables are quite complicated. We can classify billing of injectables into two major categories: prescription or buy and bill. Buy and Bill First, let’s take a look at the buy and bill process. J code — We must use the J code for in-office injectables or infusable biologics; the two currently available are alefacept 0.5mg J0215 and infliximab J1745 10mg IV. These codes must be billed in units. For example, alefacept, is given 15 mg per week, so it is billed as J0215 X 30 units. Administration code — In addition to the J code, an administration code is allowed. Therefore, for the alefacept IM injection, code 96372 can be used; for the infliximab IV infusion, 96365 can be used. (See table on next page.) Prescription While this may make writing a prescription for home administration look easy, securing prior authorization for any of these biologic prescriptions is neither simple nor easy. However, despite the burden prescribing biologics places on our office staff, the difference these drugs can make in the quality of psoriasis patients’ lives makes our efforts worthwhile, so I will continue to prescribe them. AVOIDING APPEALS AND DENIALS In reviewing appeals and denials for biologics from third-party payers, it is often the case that forms are simply either not answered fully nor correctly. We can make life a little easier for our staff if we physicians get involved in prior authorization forms. What You Must Include 1. Drug’s FDA indication — The FDA indication of the drug is very important. All biologics except infliximab are approved for moderate to severe plaque type psoriasis. Infiximab is approved for severe plaque type psoriasis. Therefore, if you mark guttate psoriasis or scalp psoriasis or mild plaque type psoriasis, your request will be immediately denied. If you mark moderate plaque type psoriasis then your request for infliximab will be denied. 2. Patient’s TB status — Most of the prior authorization forms ask if the patient has TB, so please document a negative PPD in the chart before you request the approval. This is good medical practice, and one that is necessary before starting patients on biologics. 3. Patient’s age — The patient’s age is important because none of these biologics are approved for patients under 18 years of age for psoriasis indication. While etanercept is approved for patients as young as 4 years of age for juvenile idiopathic arthritis, it is not likely to be approved for psoriasis in children. 4. Disease severity — Document that patient does not have moderate to severe (NYHA class III/IV) CHF if you prescribe TNF-a inhibitors. 5. Multiple sclerosis — Document that the patient does not have multiple sclerosis when prescribing TNF-a inhibitors. 6. Body surface area/sensitive areas — Be sure to document body surface area (BSA). Most third-party payers will allow 10% BSA or more. In addition, when BSA is less than 10%, but palms and soles or genitalia are involved, you should highlight that, as exceptions to the more than 10% BSA rule are made when sensitive areas are involved. 7. Earlier treatments — It is important to document either previous use of other systemic prescriptions or phototherapy or contraindications for any of those. If you have not previously written any prescriptions for a patient, you can request the records from previous dermatologists to show earlier treatment. What You Must Know About Contraindications and Prohibitions Prior to Prescribing 1. Cyclosporin — Even if the patient responded to cyclosporine, the FDA indication is only 1 year for psoriasis, so treatment cannot continue beyond that period. 2. Acitretin — Acitretin is certainly contraindicated in females of childbearing age. 3. Methotrexate — If the patient has had more than 1 or 2 years of cumulative methotrexate and refuses a liver biopsy, this may be a relative contraindication. Help Your Patient by Helping Your Staff Most of the requested information on PA forms is not that simple for our office staff. However, physicians can acquire this information as part of medical history and document it in the chart for quick transfer to the PA forms. Thus, we can save a lot of time and frustration for our office staff, which will lead to savings for us and faster approval for our psoriasis patients. Dr. Kircik is an Associate Clinical Professor of Dermatology at Indiana University Medical Center. His is also the Medical Director of Derm Research, PLLC, and Physicians Skin Care, PLLC, in Louisville, KY. Disclosure: Dr. Kircik has been an investigator, speaker or an advisory board member for Genentech,Serono,Amgen,Centocor, and Astellas.
