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Wiki Administration code vs Aetna Better Health D-SNP

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jtimothy

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I work in Rheumatology and we have an Aetna Better Health D-SNP patient that is receiving Cimzia (J0717) in the office. This is administered, of course, by our nurse. We normally bill 96401 x 2 for the administration portion of the drug (regardless of insurance) but we are recently receiving denials for this code stating that this is for chemotherapy drug administration only. This is not correct per the CPT book. Has anyone else run into this issue? I believe they are trying to force us to bill 96372 instead.
 
CPT book doesn't specify which drugs are complex versus therapeutic. The guidelines state what makes a drug complex/chemo (increased side effects, increased supervision, etc). There's been a lot of discussion about this specific topic, with no real clear answer. Payers can choose reimburse services according to their own guidelines/policies, which do not always follow CPT guidelines. I would pull the payer's policy regarding this drug and complex administration to determine how they are classifying Cimzia and/or the drug administration codes.
 
I've done so but this company is so vague with their guidelines. I had a co-worker help on this too as she's wonderful at digging up information. I'm sure we're going to have to start using 96372 like we have to do with all United Healthcare Advantage plans but I was hoping someone had run into this with Aetna Better Health. It's such a horrible company to be contracted with.
 
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