CPT CODE 96372, 96374 and J3301 - Therapeutic, prophylacticTestosterone Injection

cpt code and description

96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular - Average fee amount $28

96374 - Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug - average fee amount - $50 - $60

Treatment of Males with low testosterone

Group 1 Codes:

11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN)

84410 TESTOSTERONE; BIOAVAILABLE, DIRECT MEASUREMENT (EG, DIFFERENTIAL PRECIPITATION)

96372 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR

J1071 INJECTION, TESTOSTERONE CYPIONATE, 1 MG

J3121 INJECTION, TESTOSTERONE ENANTHATE, 1 MG

J3145 INJECTION, TESTOSTERONE UNDECANOATE, 1 MG

J3490 UNCLASSIFIED DRUGS

S0189 Testosterone pellet, 75 mg (Not recognized by Medicare)


Coverage Indications, Limitations, and/or Medical Necessity

Noridian has noted a rapid increase in the use of testosterone supplements that exceed the expected use in the Medicare population based on current published data. According to a Health Technology Assessment on Testosterone Testing from the Washington State Health Care Authority, the presence of low serum testosterone is 9.0% in men aged 45 to 54 years, 16.5% in men aged 55 to 64 years, and 18.3% in men aged 65 to 74 years. These estimates were derived from the National Health and Nutrition Examination Survey III (NHANESIII), which defined low testosterone levels as < 300 nanogram per deciliter (ng/dL) (10.4 nanomoles per liter [nmol/L]). The diagnosis of hypogonadism depends on measuring the total, free and/or biologically active testosterone; sex hormone binding globulin (SHBG) and the pituitary axis. Male hormone is bound to SHBG, and SHBG tends to rise with age, lowering the free testosterone level. Testosterone level accuracy varies among labs with different assays, and can be affected by chronic diseases, age, levels of binding, measurement variables, testing accuracy, etc. Estimates of the low end of testosterone depend on the method and accuracy of testing and can be as low as 160 ng/dl. Decisions on hypogonadism depend on both repeated hormone testing and a group of clinical symptoms. Neither alone is adequate for defining hypogonadism.

Testosterone levels are controlled by interaction of the testicular-pituitary-hypothalamic axis. Primary hypogonadism is failure of the testes to produce testosterone (for a number of reasons) and is usually accompanied by elevated LH and/or FSH. Secondary hypogonadism is disruption of the testicular-pituitary-hypothalamic pathway and may be due to pituitary or hypothalamic axis damage including systemic illness and genetic aberration. Age related hypogonadism (e.g. lower testosterone in the older male population) is not necessarily a disease and may be asymptomatic and / or may be related or associated with many chronic illnesses. “Low T Syndrome” or “Low T” is not a syndrome and may be an incidental finding or lab error. Low serum testosterone alone does not constitute a diagnosis of androgen deficiency or clinical hypogonadism. Diagnosis of a clinical condition requires the presence of certain characteristic symptoms as well as an abnormally low serum testosterone.

Many of the symptoms are not specific to, and not directly correlated to specific levels of testosterone. Guidelines from the Endocrine Society suggest some of the following symptoms may be related to low serum testosterone but may also have many other causes in the elderly population:

More Specific Signs / Symptoms

Incomplete or delayed sexual development; eunuchoidism

Reduced sexual desire (libido) and activity

Breast discomfort, gynecomastia

Loss of body (axillary and pubic) hair, reduced shaving

Very small (Especially < mL) or shrinking testes

Inability to father children

Low or zero sperm count

Height loss, low-trauma fracture, low bone mineral density

Hot flushes, sweats



Less Specific Signs/Symptoms

Decreased energy, motivation, initiative and self confidence

Feeling sad or blue, depressed mood, dysthymia

Poor concentration and memory

Sleep disturbance, increased sleepiness

Mild anemia

Reduced muscle bulk and strength

Increased fat or increased body mass index

Diminished physical or work performance



Noridian expects that the evaluation of primary hypogonadism be undertaken with at least 2 separate serum testosterone levels taken on two different days in the morning (when testosterone secretion is highest) , and / or two morning levels of “free” or bioavailable testosterone) and LH or FSH levels. Elevated LH /FSH confirms primary hypogonadism and the potential need for replacement hormone. If the two testosterone determinations are low AND the LH/FSH levels are also low, pituitary disease (including a serum prolactin) or chronic diseases should be assessed before making a diagnosis of age related low testosterone. Only patients with low testosterone associated significant symptoms should be considered for treatment. A comprehensive examination is required to evaluate for medications or chronic diseases known to cause decreased energy, memory problems, impotence and mental health problems.

Noridian would consider the low testosterone related symptoms from the nonspecific and specific groups described above to be documented in the chart along with two low testosterone levels drawn on two mornings and a single LH or FSH to demonstrate the need for testosterone therapy in the age related group of symptomatic androgen deficiency. Documentation of the symptoms, signs, physical examination and lab tests must be available in the chart if requested.

Treatment of symptoms associated with low testosterone is controversial. It is not certain if low testosterone is the cause of the symptoms, a marker for underlying chronic diseases, or the effect of the symptoms-and there is a considerable placebo effect. Long term effects of testosterone on the geriatric population are mixed but are being studied by the NIH. Long term use of testosterone can damage the hypothalamic-pituitary-testicular axis and lead to permanent testicular failure.

Testosterone replacement therapy is contraindicated in patients with breast cancer and untreated prostate cancer. There are recent FDA listed warnings about thromboembolic disease, increase in erythrocythemia, and hypertension. The clinical records shall reflect that these issues were discussed with the patient before initiating therapy. Some physicians recommend obtaining baseline PSA testing and ongoing monitoring to test for prostate cancer.

Long term testosterone therapy will shrink testicular tissue and can lead to infertility, and therefore would be contraindicated in those interested in reproduction.


Where replacement is indicated, the dose of replacement therapy should be the least amount necessary to obtain a serum testosterone in the low normal range. Testosterone replacement can be administered by many routes. The current preferred routes are by transdermal preparations. Since topical or transdermal agents are administered daily in low dose, the risk of supraphysiological or subtherapeutic levels is minimized. The use of topical agents is thought to minimize adverse events. Indeed, in series examining the toxicity of topical agents, adverse events are nearly nonexistent when administered by these routes (Steidle et al., 2003). The main disadvantage of the topical agents are their high cost ($100 to $150 per month), substantially higher than self-administered injection therapy, and the potential risk of inadvertent transfer of hormone to women or children through skin contact. There is no evidence that unusually high doses-or higher than published frequencies of administration-are any more effective than doses established by the FDA and could lead to increased side effects. Ongoing monitoring of hormone levels and side effects are necessary.


Reimbursement for CPT 96372 - Therapeutic Administration Fee

Peach State Health Plan will provide reimbursement for CPT 96372 (Therapeutic Administration Fee) only when reporting Synagis® injection and Depo-Provera Injection.

Reporting Injections and Infusions with Nuclear Medicine Studies

The February 2012 publication of cpt Assistant states the injection or administration of a radiopharmaceutical or nuclear medicine related drug is considered part of patient management in the course of providing nuclear medicine studies and considered inherent to the studies. Therefore, the Health Plan considers CPT codes 96365, 96369, 96372, 96373, 96374, and 96379 to be incidental to nuclear medicine studies, CPT codes 78000 – 79999, and not be eligible for separate reimbursement.


The Health Plan’s allowance for nuclear medicine studies does not include the cost of radiopharmaceuticals or nuclear medicine related drugs. The provider may report these drugs separately with the proper Healthcare Common Procedure Coding System Level II (HCPCS) J, Q, or S codes which are eligible for separate reimbursement.


Synagis® Injection

Peach State will reimburse for the Therapeutic Administration Fee plus the office visit when the Synagis®   injection, in addition to the appropriate ICD-9 code for RSV prophylaxis (V04.82), is billed by the physician’s office.

If a significant, separately identifiable E/M service is performed unrelated to the physician work (Injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.)required for the Injection service, Modifier 25 may be reported for the EM service in addition to 96372-96379.

If the E/M service does not meet the requirement for a significant separately identifiable service, then Modifier 25 would not be reported and a separate E/M service would not be reimbursed.


Hydration, IV Infusions, Injections and Vaccine Charge Process

Injections into IV lines are required to be classed into the following codes:

1. Initial injection med A (96374)

2. Additional subsequent injection, meds B – Z (96375)


3. Additional subsequent injections med A (96376), there must be a period of more than 30 minutes that has to pass between injections of same drug.


Exceptions

CPT 99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without Modifier 25. This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in addition to the procedure code for the Injection.



CMS vs CPT guidelines

Coders know to follow CPT codes, rules, and parenthetical notes but what is difficult is when CPT provides one instruction and CMS provides another. In these cases, questions often arise about what instruction should be followed. For example, CPT provides one set of guidance on how drug administration services that cross the midnight hour should be reported while CMS provides another.

The difference here is that the CPT instruction is for physicians, while CMS’ instruction is for facility reporting and coders need to keep this straight.

CPT provides the following example: a patient receives intravenous hydration from 11 p.m. to 2 a.m. A coder reports 96360 once for the initial hour of hydration and 96361 twice for the additional hours.

The explanation for why this is the correct reporting according to CPT is because this is a continuous service. However, this is exactly the same reporting under CMS’ rules but the rationale is different. From CMS’ perspective this is the correct reporting because this is one single encounter in which case only one initial service code should be used unless two separate IV sites were accessed. The CPT guidelines go on to state:

However, if instead of a continuous infusion, a medication was given by intravenous push at 10 pm and 2 am., as the service was not continuous, both administrations would be reported with the initial service (96374).

“What we know from CMS is that this reporting instruction does not apply to hospitals because they are to report only one initial service per encounter regardless of whether services are continuous or not so in the above example, hospital reporting would dictate the use of 96374 and 96376. Hospitals should continue to follow Medicare Claims Processing Manual, section 230.2, Coding and Payment for Drug Administration, which states:

Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.



FAQ about Medical Billing CPT CODE 96372

Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?


A: Yes, Oxford will separately reimburse for an E/M service (other than CPT 99211) unrelated to the physician work associated with the Injection service (CPT 96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.

Q: Will Oxford reimburse the same physician for both an injection (96372-96379) and an Evaluation and Management (E/M) service code on the same date of service if each is performed in a different place of service?

A: Yes, Oxford will separately reimburse the same physician for both an injection procedure and E/M service on the same date of service if each is performed in a different place of service (POS) and the injection was provided in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61. For example, if the patient only receives an injection at a physician’s office (POS 11) and later that day the patient is admitted to the hospital (POS 21), both services, the injection service performed at the physician’s office and the E/M performed later that day at the hospital, would be separately reimbursed because the injection service and E/M service were performed in different locations by the same physician on the same date of service. Injection services are not reimbursable when provided in POS 19, 21, 22, 23, 24, 26, 51, 52, and 61.

Q: If a Preventive Medicine E/M service is reported with an Injection code (96372-96379), will Oxford reimburse for both?

A: Yes, Oxford will reimburse for the Injection procedure and the Preventive Medicine E/M Code. When an evaluation and management (E/M) service and a procedure are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service. Since the Injection procedure does not include the components of a Preventive Medicine E/M service, the Injection can be reported separately and the Preventive Medicine E/M code does not need a modifier to indicate it is distinct or separate from the Injection procedure.




Will Oxford separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?

Yes, Oxford will separately reimburse for an E/M service (other than CPT 99211) unrelated to the physician work associated with the Injection service (CPT 96372-96379) when reported with a modifier 25. Refer to Q&A #2 for a description of the physician work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.

Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic Injection: A physician evaluates a patient’s symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the injection. The E/M service (other than CPT code 99211) should be reported with modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.



Q: Would codes 96365 and 96368 be reported in the following scenario, regardless of how long drug B was infused, following the 30 minutes of concurrent infusion? The patient is seen in the outpatient clinic for drug infusion. Drug A is administered from 6 a.m. to 7:30 a.m. Drug B is administered through the same intravenous line from 7 a.m. to 4 p.m. Upon review of the infusion interval, there are only 30 minutes when both drugs were infused concurrently. 


A: Yes. Codes 96365 and 96368 could both be reported, but reporting codes 96365 and 96367 more accurately reflects the service. Code 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, should be reported for the 1.5-hour infusion from 6 a.m. to 7:30 a.m. Code 96366, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), is not reportable  since the infusion interval did not exceed 30 minutes beyond the 1-hour increment (code 96365). This usage is stated in the parenthetical instruction ollowing code 96366.

Note that CPT codes 96365–96376 only account for the administration of the injection or infusion, not for the drug or substance infused. For example, when a patient receives 2 mg IM of Decaject, report the drug with J1100x2 and the administration of the drug with CPT 96372.



Depo-Provera Injection

Peach State will reimburse for the Therapeutic Administration Fee when billed with Depo-Provera for Contraceptive use HCPCS code J1055 and the appropriate ICD-9 code of Initiation of other contraceptive measures or other contraceptive method (V25.02 or V25.49) plus the office visit, when medically necessary.

Modifier “FP” is required to be appended to all services relating to Family Planning, per Family Planning Guidelines.

Peach State Health Plan members may obtain the generic Depo-Provera at a participating retail pharmacy and present the Depo-Provera to their provider for administration. In these cases, the provider should NOT bill J1055 on the claim since they were not supplying the medication. However, they can still bill as stated  with the appropriate diagnosis and modifiers for the administration services.


CPT 96372-FP Therapeutic Administration fee for Depo-Provera injection
CPT 992XX-FP Appropriate office E&M code for visit

Please Note: Providers must append modifier 25 to the appropriate E&M code to identify the E&M service as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.



REIMBURSEMENT GUIDELINES

Injections (96372-96379) and Evaluation and Management Services by Place of Service

Facility, Emergency Room, and Ambulatory Surgical Center Services:

Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and diagnostic injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the injection(s).

For additional information, refer to the Questions and Answers section, Q1A1.


Non-Facility Injection Services:

E/M services provided in a non-facility setting are considered an inherent component for providing an injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Health Care Professional only the appropriate therapeutic and diagnostic injection(s) will be reimbursed and the EM service is not separately reimbursed.

If a significant, separately identifiable EM service is performed unrelated to the physician work (injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for the injection service, modifier 25 may be reported for the E/M service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then modifier 25 would not be reported and a separate E/M service would not be reimbursed.
.


Topics of Frequent Interest 

Administration Fee for injectable(s) - In accordance with CPT guidelines the administration fee for injectable(s) 96372 – 96377 will be covered in addition to the cost of the drug(s), which are eligible for coverage.

After Hours Care - Services provided on weekends or holidays, or between 10pm to 8am at a facility that normally provides 24-hour services are considered mutually exclusive to an ER visit.

A facility credentialed and contracted as an urgent care center cannot submit claims for after hours care. CPT codes 99050 and 99051 are considered mutually exclusive to any service(s) provided at an urgent care center. Separate reimbursement is not allowed for mutually exclusive services.

Anesthesia - Anesthesia provided by the operating physician is considered incidental to the surgical procedure. This includes sedation given for endoscopic procedures including colonoscopy. Separate reimbursement is not provided for incidental services.


Balloon Sinuplasty – Balloon sinuplasty (codes 31295, 31296, 31297) performed in conjunction with functional endoscopic sinus surgery (FESS) is considered incidental to the major service and not eligible for separate reimbursement. Refer to policy “Surgical Treatment of Sinus Disease.”

When we currently bill J2357 with 96372 on three separate lines (because it is 3 injections) is 76 the only modifier needed.  

A: Cahaba GBA cannot advise on whether other modifiers would be needed or appropriate with the information provided. We can only advise that modifier 59 should not be used as a repeat modifier on the same procedure code being filed more than once per day. If the same procedure code is being filed more than once per day, then the services would need to be submitted with anatomical modifiers or modifier 76 or 91 as appropriate.

In regards to Injection administration with distinct different diagnosis and two shots are given is it 96372 unit 2 or 96372 and 96372-76? 

A: Our instructions regarding modifier 59 and duplicate claims processing did not change the way providers have previously been filing when multiple units of service are involved on one line item. If you have always filed with multiple units of service and have had no issues with processing, then you will continue to submit claims as you normally do.

In regards to Injection administration with distinct different diagnosis and two shots are given is it 96372 unit 2 or 96372 and 96372-76?

A: Our instructions regarding modifier 59 and duplicate claims processing did not change the way providers have previously been filing when multiple units of service are involved on one line item. If you have always filed with multiple units of service and have had no issues with processing, then you will continue to submit claims as you normally do.



CPT CODE CHANGE FROM 90772 TO 96372

The following information should be noted immediately to your chief executive officer, chief operating officer, program director, billing director, and staff.

The Current Procedural Terminology (CPT) code 90772 has been deleted from available CPT codes and eplaced with CPT code 96372. The description stays the same: “therapeutic, prophylactic, or diagnostic injection (specify material injected); subcutaneous or intramuscular.”

Although this change was made by the American Medical Association (AMA) effective January 1, 2009, providers are allowed to use either the 90772 code or the 96372 code until April 30, 2009. Claims with CPT code 90772 with dates of service of May 1, 2009 and after, will be denied.



Therapeutic or diagnostic injections/infusions (CPT codes 96360-96379) (WAC 182-531-0950)

** If no other service is performed on the same day, a subcutaneous or intramuscular injection code (CPT code 96372) may be billed in addition to an injectable drug code.

** The agency does not pay separately for intravenous infusion (CPT codes 96372-96379) if they are provided in conjunction with IV infusion therapy services (CPT codes 96360- 96361or 96365-96368).

** The agency pays for only one initial intravenous infusion code (CPT codes 96360, 96365, or 96374) per encounter unless:

** Protocol requires the use of two separate IV sites.

OR

** The client comes back for a separately identifiable service on the same day. In this case, bill the second initial service code with modifier 59, XE, XS, XP, or XU.

** The agency does not pay for CPT code 99211 on the same date of service as drug administration. If billed in combination, the agency denies the E/M CPT code 99211

Reporting Injections and Infusions with Nuclear Medicine Studies

The February 2012 publication of cpt Assistant states the injection or administration of a radiopharmaceutical or nuclear medicine related drug is considered part of patient management in the course of providing nuclear medicine studies and considered inherent to the studies. Therefore, the Health Plan considers CPT codes 96365, 96369, 96372, 96373, 96374, and 96379 to be incidental to nuclear medicine studies, CPT codes 78000 – 79999, and not be eligible for separate reimbursement.

The Health Plan’s allowance for nuclear medicine studies does not include the cost of radiopharmaceuticals or nuclear medicine related drugs. The provider may report these drugs separately with the proper Healthcare Common Procedure Coding System Level II (HCPCS) J, Q, or S codes which are eligible for separate reimbursement.

 Billing for the Administration of Xolair

Please be advised the code for billing in the memo dated August 23, 2011 was transposed. The correct code is 96372. We apologize for any inconvenience this error may have caused our provider network.

During a recent desk audit, Gateway Health Plan® identified providers that are billing CPT code 96401 for  Xolair administration. Procedure code 96401 is defined as subcutaneous or intramuscular injections of non-hormonal anti-neoplastic agents. Although Xolair is a monoclonal antibody, the mixing, administering and subsequent observation period for Xolair does not rise to the definition of the use of 96401 (highly complex biologic agent administration). This may be contrary to information from the pharmaceutical company. Instead, 96372 therapeutic prophylactic or diagnostic injection, subcutaneous or intramuscular (therapeutic injections and infusions) is the appropriate code for the administration of Xolair.

Effective September 1, 2011, please bill for the administration of Xolair with CPT code 96372.


Therapeutic, prophylactic, and diagnostic injections and infusions

Therapeutic, prophylactic, and diagnostic injections and infusions serve to administer substances or drugs (e.g., antibiotics) to patients. These services are not for hydration, chemotherapy, or other highly complex drug or biologic agent administration. When a physician uses fluid to administer the drug(s), the administration of the fluid is considered part of the therapeutic, prophylactic, or diagnostic service (i.e., not separately reportable). Hydration is not reportable in addition to therapeutic, prophylactic, or diagnostic injections and infusions.

The CPT Manual organizes the therapeutic, prophylactic, and diagnostic injection and infusion codes according to the method by which the patient receives the service:

¦ Codes 96365–96368 for IV infusion

¦ Codes 96369–96371 for subcutaneous infusion

¦ Codes 96372–96376 for injections


Reimbursement for CPT 96372

Therapeutic Administration Fee

Peach State Health Plan will provide reimbursement for CPT 96372 (Therapeutic Administration Fee) only when reporting Synagis® injection and Depo-Provera Injection.


Depo-Provera Injection

Peach State will reimburse for the Therapeutic Administration Fee when billed with Depo-Provera for Contraceptive use HCPCS code J1055 and the appropriate ICD-9 code of Initiation of other contraceptive measures or other contraceptive method (V25.02 or V25.49) plus the office visit, when medically necessary.

Modifier “FP” is required to be appended to all services relating to Family Planning, per Family Planning Guidelines.

Peach State Health Plan members may obtain the generic Depo-Provera at a participating retail pharmacy and present the Depo-Provera to their provider for administration. In these cases, the provider should NOT bill J1055 on the claim since they were not supplying the medication. However, they can still bill as stated  with the appropriate diagnosis and modifiers for the administration services.

CPT 96372-FP Therapeutic Administration fee for Depo-Provera injection

 CPT 992XX-FP Appropriate office E&M code for visit

Please Note: Providers must append modifier 25 to the appropriate E&M code to identify the E&M service as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the same Day of the Procedure or Other Service.



Can u bill 96372 with J3301

Ans : Yes.

Note: It would be appropriate to bill the E&M service for the abdominal pain (99XXX-25), the therapeutic drug injection code (96372), and the Kenalog (J3301) for this encounter.  When the patient is simply being seen for a therapeutic/diagnostic injection administration, it would be appropri-ate only to report the drug code and the administration. It is important to understand that the drug administra-tion contains inherent components of an evaluation and management service that is expected to be provided when rendering the service, such as; taking routine vital signs, obtaining a injec-tion history on past reactions and con-traindications, answering routine injec-tion questions, preparing and adminis-tering the injection with chart docu-mentation, and observing for any im-mediate reaction.




Can ASC's bill j codes for kenalog injection

Ans : Yes you can bill.

Note : But Medicare will not reimburse for injection code it will be denied as "This service cannot be billed separately".


Can we bill for 99211 for H1N1 vaccines to TMHP

Ans :

Note : Texas Medicaid reimburses the administration fee for up to two doses per client, any provider, when the doses are given on different dates following the ACIP guidelines. Administration of the H1N1 flu vaccine is reimbursed separately from a THSteps visit or office visit. For vaccine administration procedure codes 90465, 90466, 90471, or 90472, providers must include the H1N1 pandemic flu vaccine procedure code 90663, which will process as informational only.


CPT CODE  J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg


Correctly Count the Administration Units of J3301 

Question:

Dictation from an encounter states that the physician used 2 mL of 0.75% Marcaine and 0.25mL of Kenalog for a trigger point injection. I know I shouldn’t code the Marcaine, but would J3301 be billed at 1 unit? Minnesota Subscriber



Answer:

Yes, you should report one unit for this situation. Code J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for triamcinolone (Kenalog) is reported per 10 mg. Kenalog comes in two strengths – Kenalog 10 is 10 mg per 1 mL and Kenalog 40 is 40 mg per 1 mL An injection of 0.25 mL of Kenalog-10 would be 2.5 mg, whereas 0.25 mL of Kenalog-40 would be 10 mg.

best practice: You don’t specify which strength Kenalog your physician injected, but we’re assuming it was  Kenalog-10 since you refer to J3301. Work with your providers to ensure that their documentation includes the specific drug that is administered as well as the total amount injected (mg, mcg, or Gm, not the volume).

You are also correct in not billing separately for the Marcaine administration. Similar to Lidocaine, Marcaine is a local anesthetic that is used in part to numb an area as part of a diagnostic/therapeutic injection. The local nesthetic is bundled by most payers into the code for the injection and as such is not separately payable. q Translate ‘Atlanto-Occipital’ or ‘Atlanto-Axial’ Joint as ‘Paravertebral’


Q. How do you report an intralesional Kenalog injection?

A. The injection is reported with CPT 11900 for up to and including seven lesions or 11901 for more than seven lesions. Note, the descriptor says lesions, not needle sticks. A lesion may involve more than one needle stick.

To report the Kenalog, use the HCPCS code J3301.

This J code is for triamcinolone acetonide per 10mg.

The instructions for this code state to use for Kenalog- 10, Kenalog-40, Triam-A. This code may be billed in multiple units. Thus, if 20mg were used, report J3301 with 2 in the units box (box 24G on the CMS -1500 form).

Example#3: J3301 Triamcinolone Acetonide, (Kenalog-10, Kenalog-40) per 10 mg

• Your bottle says Kenalog 40 =40mg/ml

– If you use 0.25 cc 10 mg/40 mg = 1 Unit

– If you use 0.5 cc 20 mg/40 mg = 2 Units

– If you use 0.75 cc 30 mg/40 mg = 3 Units

– If you use 1.0 cc 40 mg/40 mg = 4 Units

ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

D35.2 Benign neoplasm of pituitary gland
E23.0 Hypopituitarism
E23.1 Drug-induced hypopituitarism
E23.3 Hypothalamic dysfunction, not elsewhere classified
E23.6 Other disorders of pituitary gland
E23.7 Disorder of pituitary gland, unspecified
E29.1 Testicular hypofunction
E29.8 Other testicular dysfunction
E89.5 Postprocedural testicular hypofunction
N50.89 Other specified disorders of the male genital organs


Testosterone Overview

Testosterone is an endogenous androgen. Endogenous androgens are responsible for the normal growth and development of the male sex characteristics. Testosterone levels vary from hour to hour; periodic declines below the normal range can occur in some otherwise normal men. In certain medical conditions such as hypogonadism, the endogenous level of testosterone falls below normal levels. The diagnosis of androgen deficiency is made in men with consistent signs and symptoms and unequivocally low serum testosterone levels. Testosterone levels should be determined in the morning, and studies should be repeated in patients with subnormal levels.

Testosterone pellets (Testopel®) have been approved by the Food and Drug Administration (FDA) in adult males for the treatment of primary hypogonadism (congenital or acquired) and hypogonadotrophic hypogonadism (congenital or acquired). Primary hypogonadism includes such conditions as testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testes syndrome; or orchidectomy. Hypogonadotrophic hypogonadism (secondary hypogonadism) includes conditions such as idiopathic or gonadotropic luteinizing hormone releasing hormone (LHRH) deficiency or pituitary-hypothalamic injury from tumors, trauma or radiation. Testopel Pellets are not FDA-approved for administration to females.

Guidelines

Medicare will consider testosterone pellets (Testopel®) medically reasonable and necessary for the following indications:

* Second line testosterone replacement therapy in males with congenital or acquired endogenous androgen absence or deficiency associated with primary or secondary hypogonadism when other standard replacement [intramuscular (IM), buccal, transdermal] is not clinically effective; OR,

* For treatment of delayed male puberty.

Testosterone pellets (Testopel®) method of administration is subcutaneously by a health care professional.

Limitations

Androgens are contraindicated in men with carcinomas of the breast or with known or suspected carcinomas of the prostate.

For patients that clearly meet the indication for testosterone replacement, the reason(s) for a transition to pellets from other effective replacement (IM, buccal, transdermal) must be specifically addressed in the medical record. Clinical diagnosis of androgen deficiency (non-specific symptoms, low normal testosterone levels, and normal free testosterone) is not a covered indication. Office practices with high utilization of testosterone pellet implantations can be subject to pre- or post-payment review.

Implantable testosterone pellets for the treatment of symptoms associated with menopause is considered not reasonable and necessary as there is insufficient clinical evidence to support this use and is therefore non-covered. Documentation Requirements

The medical record must substantiate the medical need for testosterone pellets (Testopel®) with documentation of unsuccessful treatments of standard replacement (IM, buccal, transdermal) on more than one occasion, in men with clinically significant symptoms of androgen deficiency.

The reason(s) for a transition to pellets from other effective replacement (IM, buccal, transdermal) must be specifically addressed in the medical record.

The medical record should reflect two total testosterone and free testosterone levels when indicated to determine the medical necessity of testosterone replacement. It is suggested to measure morning total testosterone level by a reliable assay on two different days. The results of both tests must fall below the normal laboratory reference range. The medical record should include the Clinical Laboratory Improvement Amendments (CLIA) approved reference normal range for the testosterone assay used.

CPT Code Description

11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) CPT® is a registered trademark of the American Medical Association

HCPCS Code Description

J3490 Unclassified drugs (Testopel)

S0189 Testosterone pellet, 75 mg (Not recognized by Medicare)

ICD-10 Diagnosis Code Description
C75.1 Malignant neoplasm of pituitary gland
C75.2 Malignant neoplasm of craniopharyngeal duct
D35.2 Benign neoplasm of pituitary gland
D35.3 Benign neoplasm of craniopharyngeal duct
E23.6 Other disorders of pituitary gland
E29.1 Testicular hypofunction
E30.0 Delayed puberty
N44.00 Torsion of testis, unspecified
N44.01 Extravaginal torsion of spermatic cord
N44.02 Intravaginal torsion of spermatic cord

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