Reply To: Reimbursement for infliximab

[Mandi Murph]

We had a 2 problems this past week (Jan- Feb) achieving a stream line auth for infliximab for 2 pts with grade 4 colitis, steroid refractory. One of our MD’s meet with our financial team & administration.
What emerged from that meeting was the following update & practice suggestion:

The LCD for Medicare was updated 11/1/17 to reflect approval for infliximab
-using the ICD-10 code “K52.1-Toxic Gastroenteritis and Colitis”

. For those patients who do not respond promptly (within 72-96 hours) to therapy with high-dose corticosteroids, Infliximab 5mg/kg may be utilized according to NCCN and ESMO guidelines, and soon ASCO guidelines. It has been included in the BMS algorithms for a decade.
To overcome issues with getting infliximab approved urgently for patients with ICI related diarrhea/ colitis and ensure that the financial team has all appropriate clinical information to obtain insurance authorization, the following is suggested

Clearly document a diagnosis of ICD-10 Code “K52.1-Toxic Gastroenteritis and Colitis” in the following places:

· Progress note for the related encounter
· Problem List
· Diagnosis used for professional billing when you close the encounter

I hope this update will be helpful to all & we will keep you posted with any barriers that we encounter- if any!