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  • Office-Based Infusion & Injection Coding/Payment Information

    Infusion and injection codes can be grouped into the following three categories of drug administration services: a) infusions for hydration; b) non-chemotherapy therapeutic, prophylatic, diagnostic infusions or injections other than hydration; and c) chemotherapy administration (other than hydration) including infusions and injections. While the newly structured CPT infusion and injection codes make billing more complex, they also describe the work being performed more accurately, which should be beneficial in the long-term.

    Infusion and Injection Codes  

    Revised Drug Payment Rates 

    Patient Access Problems  

    Infusion and Injection Codes

    In 2009, the CPT infusion and infection codes for hydration and for non-chemotherapy therapeutic, prophylatic, or diagnostic drug administration were renumbered. This renumbering placed the new codes (96360-96375) sequential to the chemotherapy administration codes (96401-96549) for ease of reference to providers and their billing staff. The renumbered CPT infusion and injection codes that ID physicians are most likely to use include: 96365, 96366, 96367, and 96368. These are the codes for the first hour of a drug (e.g., antibiotic) infusion, subsequent hours of infusions, sequential infusions, and concurrent infusions, respectively.

    While no changes were made to the structure or nomenclature of the renumbered codes, the CPT 2009 Professional Edition introductory language now specifies variations in coding instructions between the outpatient and inpatient settings. Specific CPT coding instructions and payment rates for the outpatient setting are available here.

    Part B Drug Payment Rates

    Medicare reimburses physicians for the cost of Part B drugs and biologicals at the Average Sales Price (ASP) plus 6 percent. The ASP for each drug/biologic is updated on a quarterly basis using pricing from drug manufacturers. Due to the complexity of pricing data, there is a delay between the submission of data and implementation of the ASP. As a result, 1st Quarter data determines 3rd Quarter ASP payments and so on.

    A PDF including third quarter 2011 Medicare payment rates for select Part B drugs and biologics infused by ID physicians is available here. CMS also publishes a quarterly pricing list for all Part B drugs and biologicals.

    Patient Access Problems

    IDSA believes that significant flaws exist within the ASP drug payment rates that CMS has publishes on a quarterly basis. As an example, some infectious diseases physicians have expressed concern regarding the supply and acquisition costs of Intravenous Immune Globuline (IVIG) administered in the physician office setting.

    Please let IDSA staff know immediately, if you have evidence of patient access problem to essential drugs and biologics in your community as a result of the ASP payment formula.

    *Important: Local Medicare carriers should have additional information available on their websites as these changes are implemented. Please click here to download the Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy.


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