Chemotherapy administration codes should be reported for highly complex drugs or biologic agents that require advanced practice training; special considerations for preparation, dosage, or disposal; and frequent patient monitoring or infusion rate changes.
Effective April 26, 2022, the following drugs should not be reported with administration codes 96401 – 96459.
- J0215 Injection, alefacept, 0.5 mg
- J0480 Injection, basiliximab, 20 mg
- J0517 Injection, benralizumab, 1 mg
- J0638 Injection, canakinumab, 1 mg
- J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered)
- J0897 Injection, denosumab, 1 mg
- J1000 Injection, depo-estradiol cypionate, up to 5 mg
- J1380 Injection, estradiol valerate, up to 10 mg
- J1410 Injection, estrogen conjugated, per 25 mg
- J1435 Injection, estrone, per 1 mg
- J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg
- J1826 Injection, interferon beta-1a, 30 mcg
- J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg
- J2357 Injection, omalizumab, 5 mg
- J3315 Injection, triptorelin pamoate, 3.75 mg
- J7178 Injection, human fibrinogen concentrate, not otherwise specified, 1 mg
- Q3027 Injection, interferon beta-1a, 1 mcg for intramuscular use
- Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use
The administration of these drugs and biologics does not meet the level of complexity required to report chemotherapy administration codes. They should be reported with therapeutic, prophylactic, and diagnostic injections and infusion administration codes 96360 – 96379.
The AmeriHealth Enhanced Claim Editing Program supports our commitment to ensure compliance with reporting requirements and guidelines endorsed by national and regional industry sources. We continue to evaluate and review our claim payment policies, industry standard sources, and specialty societies to identify additional claim edits and make changes where necessary.
The industry standard sources include but are not limited to:
- American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
- U.S. Food and Drug Administration (FDA)
- Thomson MICROMEDEX® (DRUGDEX®, DrugPoints®)
- National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium
- Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual
Resources
For further questions about the enhanced claim editing process, review our Enhanced Claim Editor Program: Frequently asked questions (FAQ). The FAQ will be updated as more information becomes available.
If you still have questions after reviewing these resources, please send an email to ahclaimeditquestions@amerihealth.com.