Injections and infusions
All plans. For Medicare members, coverage is determined by the Centers for Medicare and Medicaid Services (CMS); if a coverage determination has not been adopted by CMS, this policy applies.
Infusion Services & Equipment - 91414
Infusion and injection services prior authorization
Priority Health requires that all home infusion providers get prior authorization for their services. Use the IV Infusion Services Authorization Form.
Some injectable drugs require prior authorization. See drug-specific pages for authorization and billing information.
Injection and infusion services billing
Billing for the drug
Priority Health requires CPT or HCPCS codes (i.e., J-codes) when you are billing for injectable drugs.
- All unspecified codes will be denied unless the drug, dosage and NDC number 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 allowed 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 email@example.com.
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.
Billing for drug administration
- 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.
Not reimbursable in a hospital/facility setting: 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)
See the preventive service codes page.
Do not use therapeutic and diagnostic injection codes to report allergy injection services. See Allergy injections/immunotherapy.