Article - Billing and Coding: Prolonged Drug and Biological Infusions Started Incident To a Physician’s Service Using an External Pump (A55134)

CMS National Coverage PolicyN/AArticle TextUnder 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 physicians office or the hospital outpatient department under the supervision of a physician. Medicares 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 physicians service even though the entire administration of the drug or biological did not occur in the physicians office or the hospital outpatient department. For complete information, please see MLN Matters SE1609.Part A: Administration of Non-Chemotherapy Drug InfusionsWhen 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 InfusionsWhen 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 InfusionsHCPCS code G0498 is to be used when billing prolonged drug and biological infusions for chemotherapy administration started incident to a physicians 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).