Visante 
The American Medical Association (AMA) is responsible for the maintenance of the Current Procedural Terminology (CPT) codes. Drug administration services are reported with CPT codes in the range 96360-96379 for Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions, and range 96401-96549 for Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration. Drug Administration services codes are typically billed on outpatient claims.
The CPT manual provides guidance on when the higher-reimbursed “Chemotherapy/Highly Complex” codes can be used which includes non-radionuclide anti-neoplastic agents, anti-neoplastic agents provided for noncancer diagnoses or substances such as certain monoclonal antibody agents (“MABs”) and other biologic response modifiers. Drugs which are included as billed with “Chemotherapy/Highly Complex” codes meet detailed criteria including requiring advanced training and competency for administration, have special considerations for preparation, dosage, or disposal and present significant patient risk and frequent monitoring. Additional criteria and examples are included in the CPT 2021 Professional Edition.
In the Medicare Claims Processing Manual (100-04), Chapter 12, Section 30.5, (pg. 28 pdf), CMS provides guidance that typically, infliximab, rituximab, alemtuzumab, gemtuzumab and trastuzumab are considered to fall under the category of monoclonal antibodies and that leuprolide and goserelin acetate fall under the category of hormonal antineoplastics. CMS notes that this is not intended to be a complete list and that the MACs may provide additional guidance as to which drugs may be considered to be chemotherapy under Medicare.
Previously, MACs would provide guidance in Local Coverage Articles (LCAs) both for drugs which should not be billed with chemotherapy administration codes and those which could.
One example is a “retired” LCA from Noridian. This LCA stated that drugs in the J9000-J9999 range could be billed with chemo administration codes as well as drugs listed as Group 3 or Group 4 codes.
However, it looks like there has been a procedural change. We’ve reviewed LCAs from all MACs and find the MACs are no longer listing drugs that can be billed with chemotherapy codes just based upon the drugs but instead are only listing those drugs that can’t be billed with chemotherapy codes. In fact, the current LCA (effective 07/23/2021) contains the following language:
“The Medicare Administrative Contractor has determined in review of submitted claims that there is inappropriate use of CPT codes 96401-96549 for Chemotherapy and other highly complex drug or highly complex biologic agent administration.”
The current LCA from Noridian: Local Coverage Article: Billing and Coding: Complex Drug Administration Coding (A58532) no longer contains a list of drugs permitted to be billed with a chemotherapy code.
Although not stated, we suspect that the MACs will determine the appropriate use of chemotherapy administration codes based upon the medical record documentation rather than a “pre-approved” listing of drugs. Consequently, complete medical record documentation meeting the detail of the CPT codes will be even more important to substantiate chemotherapy drug administration services billing in the outpatient setting.
SHOUT-OUTS
1. Coding Teams should be made aware of this procedural change in instruction from the MACs and ensure that billing with chemotherapy administration codes is substantiated by documentation in the patient’s medical record.
2. Revenue Integrity should review any “hard-coded” logic that may have automated the process for billing chemotherapy administration codes with the previously listed drugs to ensure that chemotherapy administration codes are not inadvertently billed based upon the drug name alone.
3. Revenue Integrity should periodically audit a sample of claims billed with chemotherapy administration codes to ensure that the medical record documentation meets the CPT definitions.
