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

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).