Wiki 96413 versus 96365

[mneikirk]

Received letter from Humana's medical review department informing me that 96413 was not supported for administration of J0129 (Orencia). They stated that a more appropriate code for the administration of this medicine. Any assistance would be appreciated.

 

[trarut]

Are you administering the Orencia as an infusion or a subcu injection? Orencia is not an antineoplastic so payers will typically not allow 96413 unless they acknowledge the complexity of administration in their coverage policy and specifically state 96413 should be used to report the administration. I would use 96365 unless you can prove that the complexity of the drug administration supports using 96413 instead of 96365, you may be able to get an overturn on appeal but I've not personally known this to be successful. Others may have different experience with it.