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From: The Rheumatologist, December 2011

A Rheumatologist’s Dilemma—96372 vs. 96401

When coding rheumatology medical services, some coders are perplexed when it comes to coding for monoclonal antibody injections. When the American Medical Association Current Procedural Terminology (CPT) Editorial Panel updated the drug administration codes in 2006, it raised a question: What type of drugs would fall under chemotherapy administration injection?

When new drugs are approved, the ACR receives inquiries concerning whether to code the drug administration as 96372 or 96401. The 2011 CPT describes procedural code 96372 as “typically requiring direct physician supervision for any or all purposes of patient assessment,” whereas 96401 “includes other highly complex drugs or highly complex biologic agents.” Keep in mind that both procedures require direct supervision, but the greatest difference in choosing the appropriate code is in the type of drug that is used.

CPT Code 96372

CPT code 96372 is defined as a “therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.” Drugs that rheumatologists typically administered under 96372 are injectable gold sodium thiomalate (Myochrysine) and denosumab (Prolia).

CPT Code 96401

The CPT manual defines code 96401 as “chemotherapy administration, subcutaneous or intramuscular; nonhormonal antineoplastic.” This is a higher-reimbursed code than 96372 because of the intensity of the drugs administered under this code. The drugs used on this procedural code are:

  • Certain monoclonal antibody agents and other biologic response modifiers;
  • Nonradionuclide antineoplastic drugs; and
  • Antineoplastic agents that provide for the treatment of noncancer diagnoses.

Drugs that rheumatologists typically use that are administered using the code 96401 are methotrexate (Rheumatrex, Trexall) and certolizumab (Cimzia).

In 2006, the new permanent codes were created to use for drug administration. The Medicare Claims Processing Manual, chapter 12, states that the Centers for Medicare and Medicaid Services (CMS) has permitted the coding of 96401 for nonchemotherapy monoclonal antibody agents and biologic response modifiers. The manual provides a sample list of the drugs considered under this category, but the sample list is not inclusive of all approved drugs. Rheumatology practices should verify with all carriers the complete list of their approved drugs.

Because chemotherapy services come with a high level of risk, there is a need for direct physician supervision; the administration of chemotherapy drugs requires a higher level of work for both the physician and the clinical staff. Also, because of the greater level of risk to the patient and to the provider administering the medication, the code 96401 has a higher nonfacility relative value unit (RVU), which is a total of 2.01 compared with that of 96372 codes, which have a RVU of 0.68. RVUs are used to determine the Medicare Fee for Service Fee Schedule for Medicare Part B.

Incorrect coding of these drugs can result in severe under- and or overpayment errors. Education of practice coders and billers will ensure that all charges are billed out correctly the first time.

For additional questions or concerns about any coding matter, contact the ACR’s coding specialist Melesia Tillman, CPC-I, CRHC, CHA, at (404) 633-3777, ext. 820, or mtillman@rheumatology.org, or join the ACR coding list serve at www.rheumatology.org/membership and post your questions online.

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