Provider-Administered Drugs Coding Policy

POLICY NUMBER

None

DESCRIPTION

None

POLICY

The purpose of this coding policy is to provide reporting guidelines when submitting claims for subcutaneous or intramuscular therapeutic or diagnostic provider-administered injections in a professional clinical setting to Blue Cross & Blue Shield of Mississippi (BCBSMS). This policy does not apply to institutional claims filed using 837I/UB-04 claim forms. The policy also addresses self-administered drugs that are safely and effectively administered by a patient or caregiver without medical supervision.

This policy does not specifically address intra-arterial or intravenous injections, infusions, or injections for allergen immunotherapy or immunizations.

Compliance with this policy does not guarantee reimbursement. Reimbursement is determined by other factors including, but not limited to, BCBSMS’ Medical Drug Formulary, contract benefits, Medical Policy, medical necessity criteria and/or prior authorization requirements.

Provider-Administered and Self-Administered Drugs

Provider-administered drugs are drugs that ordinarily cannot be self-administered and includes chemotherapy drugs, immunosuppressants, and other miscellaneous drugs and solutions. These drugs may be administered by a physician or by another qualified medical practitioner, such as a physician assistant or nurse practitioner.

Self-administered drugs include oral dosage formulations, topical formulations, inhaled products (e.g. nebulizers, etc.) or self-administered injectable(s). These drugs are administered by the patient and are not provider-administered nor do they require the presence of a physician or other qualified medical practitioner.

Self-administered drugs are not to be submitted for reimbursement through the medical benefit; only through the prescription drug benefit. If submitted through the medical benefit, both the self-administered drug(s) and the corresponding drug administration code(s) on the claim may be denied. Any drug administered and submitted for reimbursement, whether through medical or prescription drug benefits, must align with the FDA approved indications and FDA prescribing information.

BCBSMS will continue to apply clinical policy to ensure not only that the drug is medically reasonable and necessary for any individual claim, but also that the route of administration is medically reasonable and necessary. If a drug is available in both a provider-administered and self-administered injectable form, the provider-administered injectable form of the drug must be used by the provider when seeking reimbursement from BCBSMS through medical benefits for either the drug and/or drug administration service.

Coverage and medical necessity criteria for reimbursement of specific drugs are defined in our online Medical Policies located on MyBlueProvider and/or at www.bcbsms.com .

Providers may also refer to the Medical Drug Formulary for drug coverage information for BCBSMS’ Local Fully-Insured,  Self-Insured members and State Health Plan (State and School Employees’ Health Insurance Plan). 

Coding and Billing Guidelines

Drug Reporting

Providers must ensure that drug(s) administered to a member are reported accurately using national coding guidelines, including but not limited to, the appropriate CPT/HCPCS procedure codes, ICD-10 diagnosis codes, modifiers, valid place of service codes, and the valid 11-digit National Drug Codes (NDCs) of the drug administered. 

Effective January 1, 2023, when a subcutaneous or intramuscular therapeutic or diagnostic drug requires a healthcare provider to administer, drug administration codes 96372, 96401 or 96402 must be billed along with the 11-digit NDC which identifies the drug administered. The NDC and quantity information is entered in the loop 2410 of the 5010 professional claim transaction (837P).

The following is an example of how the data appears in the 837P where NDC 44567070125 with 1 International Unit is reported with CPT code 96372 on the first line item of the claim. (Note that this example data does not show the entire claim, it starts with the line level Loop 2400 [LX segment] and continues through the end of the NDC info Loop 2410 [LIN segment and CTP segment])

LX*1~

SV1*HC:96372:59*35*UN*1***1:2~

DTP*472*RD8*20230207-20230207~

LIN**N4*44567070125~

CTP****1*F2~

As a reminder, report provider-administered drugs using the specific CPT/HCPCS code available for the drug. Do not report drugs using a NOC (not otherwise classifiable) drug code when a specific CPT/HCPCS drug code is available. Provider must report the drug NDC and quantity in loop 2410 of the 5010 professional claim transaction (837P).

If no specific CPT/HCPCS drug code is available, providers can submit NOC codes placing information in the loop 2400 SV101-2 data element in the 5010 professional claim transaction (837P). When billing a NOC code, providers are required to provide a description in the loop 2400 SV101-7 data element. Providers are not to use the loop 2400 NTE segment to describe non-specific procedure codes with 5010.

When a portion of the drug or biological is discarded, from single use or multi-use vials, the portion discarded should be reported with modifier -JW appended. Modifiers should be reported in the loop 2400 SV101-3. Please refer to Coding Policy Modifier-JW (Discarded Drugs) regarding detailed claim filing requirements for wastage and discarded drugs effective January 1, 2023.

Drug Administration Reporting

Current Procedural codebook (CPT®) provides the following coding guidelines:

Codes 96365-96379 apply to therapeutic, prophylactic, or diagnostic IV infusion or injection (other than hydration) for the administration of substances/drugs. When fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration and is not separately reportable. These services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. These codes are not intended to be reported by the physician or other qualified health care professional in the facility setting.

Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers. 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. These services can be provided by any physician or other qualified health care professional.

When submitting claims to BCBSMS, the administration of the following drugs should not be billed using a chemotherapy administration code (96401-96549). Instead, certain drugs, including but not limited to the following drugs in their subcutaneous or intramuscular forms must be billed using CPT® code 96372, (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). This is not a comprehensive list of procedure codes applicable to this policy.

Generic/Trade Names:

Multiple Injections

When a patient receives more than one provider-administered injection on the same day, by the same rendering provider, the drug administration code (e.g. CPT code 96372) must be reported for each administration on separate lines with the corresponding NDC for each drug administered.

Drug Administration and Same Day Visit

When a drug administration service (e.g. CPT 96372) is performed on the same day as an Evaluation and Management (E/M) service (CPT Codes  99202 -99499) by the same rendering provider, both the E/M and drug administration code 96372 should not be reported. The E/M visit must be significantly, identifiable as an unrelated evaluation and management services in order to report the two services separately. To indicate the E/M visit is separate and distinct, modifier -25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) must be appended to the E/M visit if the services are filed together.

Documentation Requirements

The member’s medical record must contain documentation which fully supports the medical necessity of drug services billed. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.The medical record must include the following information:

• The name of the drug or biological product administered;

• The route of administration;

• The dosage administered (e.g., mgs, mcgs, ccs or IUs);

• The duration of the administration (for CPT codes that are time based)

When using modifier -JW to describe the portion of the drug or biological product discarded, from single use or multi-use vials, the medical record must also clearly document the amount administered and the amount wasted or discarded.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.

POLICY HISTORY

09/14/2022: New Coding Policy added.

04/06/2023: Policy clarification and example provided.

7/1/2023: Policy updated to add drug coverage information also applies to State Health Plan (State and School Employees’ Health Insurance Plan).

SOURCE(S)

2022 CPT Manual, Professional Edition

2022 HCPCS Level II Professional Manual

https://www.cms.gov/medicare-coverage-database

CODE REFERENCE

None