LCD Reference Article Billing and Coding Article

Billing and Coding: Prolonged Drug and Biological Infusions Started Incident To a Physician’s Service Using an External Pump

A55134

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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General Information

Source Article ID
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Article ID
A55134
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Prolonged Drug and Biological Infusions Started Incident To a Physician’s Service Using an External Pump
Article Type
Billing and Coding
Original Effective Date
05/09/2016
Revision Effective Date
02/16/2023
Revision Ending Date
N/A
Retirement Date
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Article Guidance

Article Text

Under section 1861(s)(2)(A) of the Social Security Act (the Act), Medicare will pay for drugs and biologicals which are not usually self-administered by the patient furnished as “incident to” physicians’ services rendered to outpatients. In order for Medicare to pay for a drug or biological under section 1861(s)(2)(A) or (B) of the Act, the physician or hospital (respectively) must incur a cost for the drug or biological. Generally, the administration of drugs or biologicals covered by Medicare under the “incident to” benefit (1861(s)(2)(A) and (B)) will start and end while the patient is in the physician’s office or the hospital outpatient department under the supervision of a physician. Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit.

There are some situations where a hospital or office may purchase a drug for a medically reasonable and necessary prolonged drug infusion, then begin the drug infusion in the care setting using an external pump, send the patient home for a portion of the infusion duration, and have the patient return at the end of the infusion period. In this case the drug or biological continues to be covered and is billable incident to a physician’s service even though the entire administration of the drug or biological did not occur in the physician’s office or the hospital outpatient department. For complete information, please see MLN Matters® SE1609.

Part A: Administration of Non-Chemotherapy Drug Infusions

When reporting services for prolonged drug infusions using an external pump that were initiated in the hospital or office setting, Part A Providers should continue to report any applicable CPT/HCPCS codes for the drug or biological and its administration, and should report procedure code 96379 for the use of the external pump. The word “PUMP” should be entered in the REMARKS section of the CMS-1450 (UB-04) claim form or the electronic equivalent to indicate the claim is for use of an external pump for the administration of prolonged drug infusion services. CPT code 96379 may be payable through APC and should be reported on a single line for each date of service.

Part B: Administration of Non-Chemotherapy Drug Infusions

When reporting services for prolonged drug infusions using an external pump that were initiated in the hospital or office setting, Part B Providers should continue to report any applicable CPT/HCPCS codes for the drug or biological and its administration, and should report procedure code 96379 for the use of the external pump. The word “PUMP” should be entered in block 19 on the CMS-1500 claim form or the electronic equivalent to indicate the claim is for use of an external pump for the administration of prolonged drug infusion services. CPT code 96379 should be billed on a single line for each date of service.

Part A and Part B: Administration of Chemotherapy Drug Infusions

HCPCS code G0498 is to be used when billing prolonged drug and biological infusions for chemotherapy administration started incident to a physician’s service using an external pump. It is not necessary to include the word “PUMP” in block 19 or the equivalent section for electronic claims.

Note: HCPCS code G0498 includes the chemotherapy administration, providers should not report HCPCS code G0498 with CPT code 96416 (Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump).

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Coding Information

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CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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XX000 Not Applicable
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ICD-10-CM Codes that DO NOT Support Medical Necessity

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XX000 Not Applicable
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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

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Other Coding Information

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
02/16/2023 R7

Article revised and published on 2/16/2023 to remove reference to MLM Matters MM9749 in the Article Guidance section and Other URLs section.

01/01/2023 R6

Article revised and published on 01/26/2023 effective for dates of service on and after 01/01/2023 to reflect the Annual HCPCS/CPT Code Updates. For the following CPT code either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays: 96379 in Group 1 Codes.

11/21/2019 R5

Article revised and published on 11/21/2019. Due to system changes the order of the Coding Section has been revised and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

04/01/2017 R4 Article revised and published on 05/11/2017 effective for dates of service on and after 04/01/2017 to add a note as clarification that HCPCS code G0498 should not be reported with CPT code 96416 per TN 3728, CR 10005.
01/01/2017 R3 Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS code(s) either the short description and/or the long description was changed. Depending on which description is used in this Article, there may not be any change in how the code displays in the document: G0498.
10/13/2016 R2 Article updated on 11/10/2016 to add HCPCS code G0498 to the CPT/HCPCS Codes Group 1 list.
10/13/2016 R1 Article revised and published on 10/13/2016 effective for dates of service on and after 01/01/2016 to add guidance for HCPCS code G0498 per CR9749.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
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