Loading...Loading...Policy No: 109
Date of Origin: 05/01/2009
Section: Administrative
Last Reviewed: 10/01/2024
Last Revised: 10/01/2019
Approved: 10/10/2024
Effective: 11/01/2024
Policy Applies To: Group and Individual & Medicare Advantage
This policy applies only to physicians and other qualified health care professionals.
Injection and Infusion Services
An injection or medication administered subcutaneously, intramuscular or intravenously. Common Procedural Terminology (CPT®) identifies these services that are not intended to be reported by a physician when the service is provided in a facility setting.
Our health plan will not reimburse or permit a provider to retain reimbursement for services that are not intended to be performed by a physician in a facility setting. These physician charges will be denied as a provider write-off. Ambulatory Surgical Centers (ASC), with a provider type of BZ, are excluded from this policy.
Examples of these services are CPT codes 96360-96379 for infusion therapy and CPT codes 96401-96402, 96409-96425 and 96521-96523 for Chemotherapy. CPT text states: "These Injection and Infusion Services codes are not intended to be reported by the physician or other qualified health care professional in the facility setting".
Facility Place of Service codes are: | |||
|---|---|---|---|
19 | Off Campus-Outpatient Hospital | 51 | Inpatient Psychiatric Facility |
21 | Inpatient Hospital | 52 | Psychiatric Facility Partial Hosp |
22 | On Campus-Outpatient Hospital | 54 | Intermediate Care Facility |
23 | Emergency Room | 61 | Comp Inpatient Rehab Facility |
24 | Ambulatory Surgical Center | 62 | Comp Outpatient Rehab Facility |
25 | Birthing Center | 65 | End-Stage Renal Dz Tx Facility |
31 | Skilled Nursing Facility | ||
32 | Nursing Facility | ||
34 | Hospice, Free Standing | ||
NCCI Policy Manual, current version, Chapter XI
Current Procedural Terminology (CPT®) Manual, American Medical Association. Current year version
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.