Injection & infusion billing
Priority Health requires CPT or HCPCS codes (i.e., J-codes) when you are billing for injectable drugs and chemotherapy drugs. See more details in the Priority Health Infusion Services and Equipment medical policy.
- All unspecified codes will be denied unless the drug and dosage are specified, since we must review them on a case-by-case basis.
- If you are billing for a dosage other than that specified by the HCPCS code, first verify that there is not another code specifically for the dosage administered. If not, report the HCPS code with the number of units representing the higher dosage (not the total dosage).
Example: You administer 250 mg. The code description of the injection is listed at 50 mg.
You report the code and 5 units (not 250 mg).
- Some injectables are subject to maximum unit edits. See details.
Priority Health Medicare Advantage plans: Part B vs. Part D injections
- Drugs infused by IV pump in a physician office, outpatient setting, or home (for home-bound patients only) are considered Part B drugs. Follow Medicare billing rules.
- Drugs infused via IV push are considered Part D drugs when administered in the home unless listed in the Medicare formulary with HI in the 3rd column. Part D drugs bill through the Priority Health pharmacy benefit manager, Express Scripts®. Call the Provider Helpline for more information, or email firstname.lastname@example.org.
NDC numbers required
When submitting claims for reimbursement of drugs, NDC (National Drug Code) numbers must be submitted on the claim in addition to the CPT code. The NDC number is a unique 11-digit number that identifies the listed drug and is unique to the product being dispensed. Learn how to use the NDC on claims.
Drug administration codes
- CPT or HCPS codes for drug administration services can be reported in addition to codes for the drugs themselves.
- When drug administration is performed in conjunction with an E&M service, the injection is considered incidental and is not separately reimbursed.
Priority Health requires that all home infusion providers get prior authorization for their services.
Some injectable drugs require prior authorization, go to the list in this manual.
Priority Health does not reimburse physician services for injection and/or infusion codes 96360 - 96376 when provided in a hospital or facility setting (Place of Service 21, 22, 23). This includes services provided by physicians in the ER.
The American Medical Association (AMA) has clarified coding guidelines associated with hydration, therapeutic, prophylactic, and diagnostic injection and infusions. A portion of the language is below; reference your CPT manual for further information.
Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting. (AMA CPT 2008)
Also see guidelines for vaccines and immunizations in this Manual.
See the preventive service codes page in this Manual.
Therapeutic and diagnostic injection codes should not be used to report allergy injection services. The quantity should always be one. See the Priority Health Allergy Testing/Immunotherapy medical policy for details.