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Policy No: 109

Date of Origin: 05/01/2009

Section: Administrative

Last Reviewed: 09/01/2018

Last Revised: 09/01/2015

Approved: 09/06/2018

Effective: 10/01/2018

This policy applies only to physicians and other qualified health care professionals.

Definitions

Injection and Infusion Services

An injection or medication administered subcutaneously, intramuscular or intravenously. Common Procedural Terminology (CPT®) identifies these services that are not intended to be reported by a physician when the service is provided in a facility setting.

Policy statement

Our health plan will not reimburse or permit a provider to retain reimbursement for services that are not intended to be performed by a physician in a facility setting. These physician charges will be denied as a provider write-off.

Examples of these services are CPT codes 96360-96379 for infusion therapy and CPT codes 96401-96402, 96409-96425 and 96521-96523 for Chemotherapy. CPT text states: "These Injection and Infusion Services codes are not intended to be reported by the physician or other qualified health care professional in the facility setting".

Facility Place Of Service codes are:

19 — Off Campus-Outpatient

21 — Hospital Inpatient Hospital

22 — On Campus-Outpatient Hospital

23 — Emergency Room

24 — Ambulatory Surgical Center

25 — Birthing Center

31 — Skilled Nursing Facility

32 — Nursing Facility

34 — Hospice, Free Standing

51 — Inpatient Psychiatric Facility

52 — Psychiatric Facility Partial Hosp

54 — Intermediate Care Facility

61 — Comp Inpatient Rehab Facility

62 — Comp Outpatient Rehab Facility

65 — End-Stage Renal Dz Tx Facility

References

NCCI Policy Manual, current version, Chapter XI

Current Procedural Terminology (CPT) Manual, American Medical Association. Current year version

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.