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Humira and Cimzia

Vickie Posted Mon 29th of April, 2013 15:24:01 PM

I would like clarification on the Administration code that should be used for Humira and Cimzia. How would it be correct to say you use 96401 for the administration of Cimzia; however, you use 96372 for the administration of Humira. When I am reading the posts on Supercoder this is what is being said. If you read the information before the code 96401 it says this code can be used for treatment of noncancer diagnoses. Humira and Cimzia both are biological agents. So if it is correct to use 96401 for Cimzia, why would it not be correct to use 96401 for Humira?

SuperCoder Answered Tue 30th of April, 2013 13:41:45 PM

My editor is working on this. Please be patient.


SuperCoder Answered Tue 30th of April, 2013 14:48:44 PM

The code 96401 says in the descriptor: "non-hormonal, anti-neoplastic". Also the sectional guideline above code 96401 says: "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 (eg, cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers."

See the first portion of the guideline that says about "anti-neoplastic" drug. It also says that it applies to "anti-neoplastic agents provided for treatment of noncancer diagnoses". this section (96401-96549) is for highly complex drug/biologic agents.

As per CPT Assistant May 2007; Volume 17: Issue 5 ("Drug Administration Services—Part 1 of 3") -->

"We are frequently asked whether the chemotherapy codes apply to all monoclonal antibody agents and other biologic response modifiers even when used for noncancer diagnoses, or whether code usage is applicable only when used for cancer diagnoses. Codes 96401-96549 describe chemotherapy services that are typically highly complex, requiring direct physician supervision and advanced training and competency for the staff providing these services. CPT 2007 (page 411 of the professional edition) indicates that "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 (eg, cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers." The mentioned drugs are only examples and do not suggest or imply any payer coverage. The codebook does not designate whether a specific drug or agent is reportable using this series of codes. Coverage determinations for specific drugs and agents are made by each third-party payer......

The provider is cautioned not to assume that the 96000 series of CPT codes would be appropriately reported for every biologic response modifier, chemotherapeutic drug, or monoclonal antibody agent. For example, the CPT Editorial Panel Drug Infusion Workgroup addressed questions related to the infusion of Leucovorin and Mesna, drugs commonly utilized in addition to an antineoplastic agent infusion. The members indicated that although these drugs are included in the HCPCS Drug Category for Chemotherapy Drugs, their inclusion in the J9000 series was done as a matter of coding convenience as these drugs are not antineoplastic agents but either modulate the effect of the antineoplastic agent or protect normal tissues. The workgroup agreed that these drugs administered as modulating agents in addition to antineoplastic agent infusion should not be reported with codes in the 96000 series of codes but would be reported appropriately by a concurrent or sequential therapeutic infusion or injection code(s), depending upon the circumstances related to the hierarchy and method of administration."

So here lies the confusion of which code to bill for ADMINISTRATION of a drug since there is no clear instruction. Coders should check with payers before using 96401 to report a drug admin. CPT’s chemotherapy administration introductory notes allow the use of chemotherapy administration codes for other non-chemotherapy agents. The definition created in 2006 meant chemotherapy administration codes can apply to substances, such as monoclonal antibody agents.

Prior to 2006, CMS had created a partial list of drugs that qualified for chemotherapy administration codes. “The following drugs are commonly considered to fall under the category of monoclonal antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab,” according to CMS Transmittal 129. The list, however, did not include Omalizumab (Xolair) or Certolizumab (CimZia), but both these drugs are considered "another drug in the same monoclonal antibody category".

CMS’ partial drug list left discretion to individual carriers. Coding specialists indicate that “certain insurance carriers will reimburse for the more complex code, 96401, generally paid at a higher level, but usually reserved for chemotherapy administration via the subcutaneous route.

Here is one more example in the same debate. Because omalizumab is not an anti-neoplastic monoclonal antibody, the American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) recommend the use of 96372.

Some payers have followed suit and frown on using chemotherapy administration code 96401 for omalizumab, which is a non-chemotherapy drug. For instance, Cigna Part B for Idaho, North Carolina and Tennessee requires the use of 96372 for Xolair administration. The Medicare carrier agrees that “Xolair (omalizumab) is a monoclonal antibody ... But because Xolair is not an anti-neoplastic as required by 96401, it would be incorrect to bill for administration of Xolair under CPT code 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.”

Instead, the Cigna Government Services July 5, 2006, article “Drug Administration Coding” instructs coders to bill the administration of the drug based on the route of administration using 96372, Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular.

CPT confirms that you should use 96372 for non-antineoplastic hormonal therapy injections. “Report 96401 for anti-neoplastic hormonal injection therapy.”

It's best, therefore to inquire with the payer to finalize which administration you could use for particular drug.

SuperCoder Answered Tue 30th of April, 2013 14:53:13 PM

Please check the CIMZIA website's page on "Quick Reference coding guidance" -->

This page, developed by Cimzia itself, has 2 options as CPT code - 96372 and 96401 :-)

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