Part B Insider (Multispecialty) Coding Alert

Published on Sun May 28, 2006 PDF

Question: Last year, a number of carriers--but not all--changed their coding preferences for Avonex injections from 90782 to G0355. I understand preferences have changed once again. How should we code this procedure accurately in 2006?


Ohio Subscriber

Answer: You’re probably perplexed because as of Jan. 1, 2006, CMS deleted HCPCS code G0355.

That throws a wrench in the rules that were  established in 2005 by several Medicare carriers--such as Empire, Health Now, and Group Health Inc.--who reconsidered the long-standing categorization of Avonex (Interferon beta-1a) as a therapeutic drug, and instead began to see the complexities of its administration. As a result, these carriers changed their coding preference for Avonex injections from CPT code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected…) to HCPCS Code G0355 (Chemotherapy administration, subcutaneous or intramuscular non-hormonal antineoplastic).

Yet not all carriers or private payors universally made the switch over to G0355 last year. Instead, some were asking providers to continue using 90782 or G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for Avonex administration.

Current problem: CMS deleted G0351 on Jan. 1, and CPT 2006 has eliminated 90782.

Solution: In the wake of recent deletions, you are left with two new options for reporting Avonex, both of which are 2006 CPT additions:

•  96401--Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic

•  90772--Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.

What to do: If you know a payor’s 2005 reporting preference, you can make a reasonable determination about which of these codes will now be most appropriate. To do this, divide your payors into two categories: Those that switched to G0355 in 2005 will likely prefer 94601, and those that stuck with 90782 or G0351 in 2005 will likely now accept 90772.