Biologic Administration Coding-Resource Tool for 2019

The administration of certain drugs and biologic agents should not be billed using a chemotherapy administration code. Instead, the subcutaneous administration of some drugs should be billed using CPT code 96372, Therapeutic, prophylactic, or diag-nostic injection.

The Centers for Medicare & Medicaid Services (CMS) provides additional guidance as to which drugs (biologics) may be considered as a form of chemotherapy under Medicare guidelines. The information can be found in Chapter 12 of the internet only manual, Medicare Claims Processing Manual (CMS Pub 100-04), Chapter 12 – Physicians/Nonphysician Practitioners (Section 30.5: Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions). The online manual can be accessed at: https://www. cms.gov/Regulations-and-Guidance/Guidance/Manu-als/Downloads/clm104c12.pdf.

The following table should not be considered all-inclusive. A few of the drugs/biologics should not be billed with a CPT chemotherapy administration code. For items not included in the table, we recommend contacting your local Medicare carrier to determine appropriate coding.

Table Key

** NUSA (Not usually self-administered): for the purposes of applying this exclusion, the term “usually” means more than 50% of the time for all Medicare beneficiaries who use the drug/biologic, regardless of the indication or route of administra-tion. Covered when provided in office setting.

* IM (Intramuscular): Absent evidence to the contrary, drugs/biologics delivered via IM are presumed as not usually self-administered (NUSA)

**USA (Usually self-administered): A drug self-administered by more than 50% of Medicare beneficiaries is excluded from coverage.

** SQ (Subcutaneous):Absent evidence to the contrary, drugs/biologics delivered via SQ are presumed to be self-administered by the patient.

**Intralesional If intralesional injections are delivered via SQ, they are presumed to be self-administered.

N/A (Not applicable): Effective on or after July 31, 2017, if the administration of these drugs is billed using a chemotherapy administration code, both the drug and the administration will be rejected as incorrect coding.

CK (Check): Check with local carrier for appropriate reporting criteria

Code descriptions:

11900 Injection, intralesional; up to and including 7 lesions

96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

96405 Chemotherapy administration; intralesional, up to and including 7 lesions

96372 Therapeutic, prophylactic, or diagnostic injections; subcutaneous or intramuscular

Sources: CGS Local Coverage Article: Self-admin-istered Drug Exclusion List (A52571) at https://www.cgsmedicare.com/pdf/drug_admin_coding. pdf and Noridian Local Coverage Article: Chemo-therapy Administration (A52953) at https://med. noridianmedicare.com/documents/10546/12461373/Chemotherapy+Administration