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Infusion services

Susan Posted Mon 08th of October, 2018 13:41:35 PM
Our office has just started doing infusions for Remicade, Entyvio and Stelara. It is clear that I bill 96413 and 96415 for Remicade, however what infusion codes are used for Entyvio and Stelara. Are modifiers used? Do you have any examples of what the claims would look like? Any help would be greatly appreciated.
SuperCoder Answered Tue 09th of October, 2018 03:16:15 AM

Hi Susan,

 

Thank you for your Question.

CMS states that the administration of Entyvio and Stelara should NOT be billed using a chemotherapy administration code as these drugs are not eligible for chemotherapy administration. Instead, these administration should be billed with an appropriate code from the range of CPT® codes 96365-96379 (infusion for therapy, prophylaxis, or diagnosis)”.

The appropriate HCPCS codes for Entyvio J3380 (Injection, vedolizumab, 1 mg) and Stelara J3358 (Ustekinumab, for intravenous injection, 1 mg).

Your billing unit for above mentioned HCPCS codes would be determined on the basis of medical record (amount of drug administered).

 

The undermentioned codes would be appropriate for infusion administration.

96365  Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366   Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96367  Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

96368   Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)

 

Note: Your billing unit for above mentioned CPT codes would be determined on the basis of medical record (as these CPT codes are time based codes).

If two separate and distinct timed services are provided in separate and distinct time intervals, modifier -59 may be used to identify the services

 

Hope this helps!

 

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