Claims for drugs/biologics should be billed using the HCPCS/CPT code that most accurately describes the drug. Information in this article concerns drug administration services provided in physicians’ offices. Under the Medicare program, the administration of the following drugs should be billed using CPT code 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
| Generic Name | Trade Name | HCPCS Code |
|---|---|---|
| Benralizumab | Fasenra | J0517 |
| Mepolizumab | Nucala | J2182 |
| Omalizumab | Xolair | J2357 |
However, other third-party payors may allow the use of CPT code 96401: Chemotherapy administration, subcutaneous or intramuscular; nonhormonal, antineoplastic. According to the American Medical Association’s CPT codebook, CPT code 96401 applies to substances including certain monoclonal antibody agents, as well as other biologic response modifiers. The CPT codebook states that “the highly complex infusion of chemotherapy or other drug or biologic agents requires physician or other qualified health care professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents (96360-96379) because the incidence of severe adverse patient reactions are typically greater.” Coverage and billing requirements for this code vary by payer, so providers should consult with the non-Medicare payer to determine whether, and under what circumstances, this code may be used.
If a significant and separately identifiable Evaluation and Management (E&M) service is performed on the same day, the appropriate nonfacility-based E&M CPT codes (e.g., 99202-99205, 99212-99215) should be reported with modifier -25 in addition to CPT codes 96372 or 96401. A different diagnosis is not required for an E&M service provided on the same day. CPT code 99211 for E&M services may not be reported with CPT codes 96372 and 96401.
In addition, under the Medicare program, the administration of reslizumab (Cinqair) – which is coded as HCPCS code J2786 – should be billed with CPT code 96365: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour. Other third-party payors may reimburse CPT code 96413: Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug. Providers should refer to payer directives to ensure proper coding.
Reporting Not Otherwise Classified (NOC) Drugs
HCPCS codes J3490 (unclassified drugs) and J3590 (unclassified biological drugs) should be reported for those drugs that have not been assigned a code. These codes include Tezepelumab (Tezspire) and Dupilumab (Dupixent), as they do not have permanent J-codes. In general, claims with these codes must be submitted with additional qualifying information such as the narrative description reflective of the agent (name of the drug and National Drug Code number), the dose administered, and the method of administration. When billing Medicare, report one unit of service in the 2400/SV1-04 data element or in item 24G of the CMS 1500 form. Billing requirements for NOC codes may vary by payer, so providers should consult with the payer to determine coverage and coding requirements.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS
