Billing and Coding: Complex Drug Administration Coding for Subcutaneous and Intramuscular Routes (A58620) Reminder
National Government Services identified claim billing errors for complex drug administration coding for subcutaneous and intramuscular routes.
Data analysis revealed some of the medications listed in this article were billed incorrectly with 96401, (chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic) or 96402, (chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic). NGS identified numerous claims and is completing overpayments for 96401 or 96402 paid in error.
Billing and Coding Article A58620, effective 5/1/2021, instructs providers it is improper billing when chemotherapy administration codes are billed for drugs in the table below. Instead, the administration of the following drugs in their subcutaneous or intramuscular forms should be billed using CPT code 96372, (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular).Generic/Trade Names
| Generic Name | Trade Name | HCPCS Code |
|---|---|---|
| benralizumab | Fasenra™ | J0517 |
| canakinumab | Ilaris® | J0638 |
| certolizumab pegol* | Cimzia®* | J0717* |
| denosumab | Prolia/Xygeva® | J0897 |
| filgrastim (g-csf) excludes biosimilars*** | Neupogen ®*** | J1442*** |
| tbo-filgrastim | Granix® | J1447 |
| filgrastim-sndz biosimilar*** | Zarxio®*** | Q5101*** |
| filgrastim-aafi*** | Nivestym®*** | Q5110*** |
| luspatercept-aamt | Reblozyl ® | J0896 |
| mepolizumab | Nucala® | J2182 |
| octreotide acetate depot | Sandotstatin LAR depot | J2353 |
| omalizumab | Xolair® |
J2357 |
| pegfilgrastim** | Neulasta®** | J2505** |
| pegfilgfrastim-jmdb, biosimilar | Fulphila® | Q5108 |
| pegfilgrastim-cbqv | Udenyca® | Q5111 |
| pegfilgrastim-bmez | Ziextenzo® | Q5120 |
| pegfilgrastim-apgf, biosimilar | Nyvepri™ |
Q5122 |
| rilonacept | Arcalyst® | J2793 |
| tildrakizumab-asmn |
Ilumya™ | J3245 |
**Note: Effective 1/1/2018, providers are instructed to use 96377 for the on body application injector for Neulasta® Onpro Kit.
***The subcutaneous or intravenous formulation of filgrastim is billed using HCPCS code J1442, Q5101 or Q5110 with the JA (intravenous) or JB (subcutaneous) modifier.
*Note: The self-administration formulation of certolizumab pegol (Cimzia® prefilled syringe as a 200 mg/1 ml unit dose) is not a Medicare benefit. Providers and facilities must bill this formulation with the GY modifier as a statutorily excluded service.
Posted 7/29/2021