MACs offer conflicting guidance on injection reporting

March 8, 2016
Medicare Web

by Jugna Shah, MPH

One of several issues involving CMS receiving inconsistent provider data has arisen due to differing MAC guidance on whether providers should report a nonchemotherapy vs. chemotherapy injection code when injecting monoclonal antibodies and/or biologic response modifiers.

CMS should clear up this question and release guidance that supersedes existing MAC guidance so that consistent data is received from providers. The two CPT codes in question are:

  • 96372, therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
  • 96401, chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic

The 96401 code is for a more complex service that requires skilled staff and resources, and pays more than CPT code 96372. The CPT book states that code 96401 is to be used for "certain monoclonal antibody agents and other biologic response modifiers, but the manual doesn't specify which drugs those could be.

The Medicare Claims Processing Manual provides examples of some drugs that are allowed to be reported with the code, but then states:

The drugs cited are not intended to be a complete list of drugs that may be administered using the chemotherapy administration codes. Local carriers may provide additional guidance as to which drugs may be considered to be chemotherapy drugs under Medicare.

This has resulted in a situation where MACs have created their own guidance on whether providers should report 96372 or 96401 for the administration of certain biologic response modifiers, which essentially contradicts what the CPT Manual states, yet it's being allowed.

As a result of MACs being allowed this discretion, despite the CPT book being clear, the data CMS receives won't consistently reflect the drug administration resources providers expend when providing biologic response modifiers or monoclonal antibodies. Two different drug administration codes with varying charges and payment rates can be reported for the administration of the exact same drug, depending on the MAC. Hopefully, CMS will address this and other anomalous data situations in the coming year.

Editor's note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.