Hospitals Must Correctly Code Claims Involving Chimeric Antigen Receptor T-cell and Other Immunotherapy to Receive Proper Payment

We have noticed that inpatient hospital claims for CAR T-cell and other immunotherapy are not always coded correctly, and this may result in improper Medicare payments under the IPPS. 

Per Change Request (CR) 11879: 

• A new MS-DRG code 018 for CAR T-cell and other immunotherapies was created.
• An adjustment to the payment amount for clinical trial and expanded access use immunotherapy cases that group to MS-DRG 018 was adopted. 
  • An IPPS payment adjustment is applied to claims that group to MS-DRG 018 and include ICD-10-CM diagnosis code Z00.6 or there is expanded access use of immunotherapy. 
  • Note: When the CAR T-cell therapy product is purchased in the usual manner, but the case involves a clinical trial of a different product, the payment adjustment is not applied. 
• You must code claims involving CAR T-cell and other immunotherapy to identify expanded access vs. the CAR T-cell therapy product was purchased in the usual manner, but the case involves a clinical trial of a different product.

Although CR13926 will be implemented on 7/7/2025 to automate certain processes described in CR11879, you must continue to follow the claim coding instructions in CR11879 and in other related CRs:

Ensure Correct Coding on Your Claims

For discharge dates on or after 10/1/2020, CAR T-cell and other immunotherapy services are billed on TOB 11X with line-item covered charges greater than a token charge of $1.00 with revenue code(s) 0891 and/or 0892.

• Expanded access
  
  When a claim includes expanded access use immunotherapy of a CAR T‑cell therapy product, add a billing note “Expand Acc Use” to 
   
  • NTE02 on the electronic 837I claim or 
  • Remarks on a paper or FISS DDE claim
     
  Also add condition code “90” so the Pricer will apply the payment adjustment. 
   
• CAR T-cell therapy product purchased in the usual manner, but the case involves a clinical trial of a different product
  
  When a claim includes a CAR T-cell therapy product purchased in the usual manner but involves a clinical trial of a different product (and ICD-10-CM diagnosis code Z00.6 is on the claim), add a billing note “Diff Prod Clin Trial” to 
   
  • NTE02 on the electronic 837I claim or 
  • Remarks on a paper or FISS DDE claim
     
  We will add payer-only condition code “ZC” so the Pricer will not apply the payment adjustment. 
   
• Note:
  • Claims that do not include billing note “Diff Prod Clin Trial” should not include line-item covered charges greater than a token charge of $1.00, since you did not purchase the product in the usual manner.
  • Claims that include revenue code(s) 0891/0892 and line-item covered charges greater than a token charge of $1.00 may be missing the billing note “Diff Prod Clin Trial,” or the line-item charges with revenue code(s) 0891/0892 may be billed incorrectly.

Related Content

• CR11879 “Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes” 
• CR12049 “Implementation of Two (2) New NUBC Condition Codes. Condition Code “90”, “Service Provided as Part of an Expanded Access Approval (EA)” and Condition Code “91”, “Service Provided as Part of an Emergency Use Authorization (EUA)”
• CR12814 “Fiscal Year (FY) 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes”
• CR13926 “Fiscal Intermediary Shared System (FISS) Changes to Automate the Application of Condition Code ZC for Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapy Cases Involving a Clinical Trial of a Different Product” 
• Chimeric Antigen Receptor (CAR) T-cell Therapy

Posted 1/24/2025