Billing and Coding: Chemotherapy Administration - R23

This coverage article has been revised and published for notice under contract numbers: 01112 (NCA), 01182 (SCA), 01212 (HI and Territories), and 01312 (NV).

Effective Date: July 1, 2020
Summary of Article Changes: The following updates were made with multiple effective dates.

  1. Effective January 1, 2019:
    • Added J0517 - benralizumab (Fasenra®) and deleted C9016 - triptorelin (Triptodur™) and C9466 - benralizumab (Fasenra®) in Group 1 of the CPT/HCPCS Codes section.
  2. Effective October 21, 2019:
    • Added the diagnosis codes for Ulcerative Colitis as payable with IV Stelara® in the Group 1 of the ICD-10 Codes that Support Medical Necessity section.
  3. Effective January 1, 2020:
    • Converted this article to Billing and Coding: Chemotherapy Administration.
    • Added information regarding how to bill for drugs that have a Not Otherwise Classified (NOC) HCPCS code and the mandatory use of the JW modifier when billing for the quantity of drug wasted per CMS CR 9603 to the Article Text section.
    • Combined and added the following information for Groups 1 and  2 Paragraphs in the CPT/HCPCS Codes section:
      • Combined Group 1 and 2 Paragraph into one group titled; Intramuscular, Subcutaneous and Intravenous Non-Chemotherapy Injections/Infusions and added all the associated J codes to the Group 1 Codes.
      • Added Group 2 Paragraph statement and listed all the administration codes associated with the Group 1 codes to the Group 2 list of codes.
      • Deleted J3590 for Orencia®, Simponi® and J1628 - Tremfya™ from all of Group 1 since these drugs are self-administered and in the current SAD article.
    • Added Coding Guidelines in the Group 3 Paragraph under the CPT/HCPCS Codes section. Some of these include:
      • Added Q5115 - rituximab-abbs (Truxima®) and Q5116 - trastuzumab-qyyp), Herceptin biosimilar (Trazimera) to the table
      • Added instructions for Part A enrolled  independent or provider-based facilities and Part B enrolled as provider-based multispecialty clinics or independent physician clinics on how to bill both the drug and administration codes for chemotherapy administration codes 96401-96425 and 96440, 96446, 96450 and 96542.
      • Added instruction for billing intravesical chemotherapy using 51720 - Bladder instillation of anticarcinogenic agent (including retention time) or 52224, 52234, 52235 or 52240 when the intravesical chemotherapy drug was administered with a fulguration procedure.
      • HCPCS code G0498, is to be bill for the drugs that are infused greater than 8 hours even if the pump is not supplied by the facility or the physician’s office.
      • Added instructions to bill 96416 instead of G0498 when the beneficiary goes to a facility or physician not associated with the billing facility or physician for the removal of the external pump.
      • Instructed providers to report 96416 as the administration code with one of the drugs approved for prolonged infusion time (greater than 8 hours) listed in the article only if the patient has an infusaport catheter with implantable pump within the catheter itself. 
    • Added a list of approved chemotherapy drug HCPCS codes in Group 3 CPT/HCPCS Codes section.
    • Added a table for all the approved chemotherapy drugs and the appropriate administration code(s), provided instructions for providers and facilities to appeal claims denied for the wrong admin code or if  96413 is billed when the appropriate administration code in the table is 96409 because the drug was infused greater than 15 minutes and what to include with the Appeal and instructed providers to add diagnosis code T45.1XA - Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter when a drug requiring more than 15 minutes is billed and the patient had an adverse reaction to the drug to the Group 4 Paragraph.
    • Added the approved chemotherapy administration codes to the Group 4 CPT/HCPCS Codes section.
  4. Effective May 1, 2020 added J9999 for daratumumab and hyaluronidase-fihj (Darzalex FasPro™).
  5. Effective July 1, 2020 added HCPCS codes J9177 - enfortumab vedotin ejfv (Padcev™),
    J9198 - gemcitabine hydrochloride (Infugem™), J9246 - melphalan HCL (Evomela),
    J9358 - fam-trastuzumab deruxtecan-nxki, (Enhertu®) , Q5119 - rituximab-pvvr (Ruxience™) and
    Q5121 - infliximab-axxq, biosimilar, (Avsola), deleted J9199 - gemcitabine hydrochloride (Infugem™) and the code description for J9245 changed from melphalan HCL (Evomela), 50mg to melphalan HCL, NOS, 50mg.

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            Last Updated Thu, 02 Jul 2020 14:50:41 +0000