Oncology & Hematology Coding Alert

Question: Which administration code would match to Provenge?Nevada SubscriberAnswer: Individual payers have final say over which administration code to apply to specific therapies. For example, Palmetto GBA has published guidance that for Provenge administration, you should use therapeutic infusion codes, such as 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour).You may find other payers who allow chemotherapy codes, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for this immunotherapy treatment, so check individual payers to be sure.Coverage: CMS recently announced its decision to cover Provenge therapy. Specifically, CMS "has determined that the evidence is adequate to conclude that the use of autologous cellular immunotherapy treatment -- sipuleucel-T; PROVENGE® improves health outcomes for Medicare beneficiaries with asymptomatic  or minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer, and thus is reasonable and necessary for that indication." [...]