Article Detail - JF Part A
Clarification on Payment for Monoclonal, Complex Biological, and Rheumatological Therapies
Claims that involve administration of monoclonal, complex biological, and rheumatological therapies should be coded as complex drug administration and will be paid as complex administration, so long as all elements of these codes that are required for appropriate billing are met. Complex drug administration codes use the same service codes as chemotherapy administration. Physician work related to complex drug administration involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of nonphysician clinical staff.
Physicians should follow the CPT coding instructions and Medicare guidance to report complex drug administration. Noridian will not make claims adjustments or edits to codes 96401-96549 based solely on the specific drug or agent administered.
For additional Medicare guidance, refer to CMS Change Request (CR) 13468 and CMS Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 30.5: Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions.
