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Claim Submission by Treatment Center

General coding and billing considerations for CAR T cell therapies

Coding and billing for CAR T cell therapies will vary based on patient’s condition, provided services, payer-specific requirements, and selected site/setting of care. It is critical for treatment sites to confirm specific payer requirements prior to claim submission in order to avoid processing delays or denials.

Unique Coding Dynamics


HCPCS Level II Codes

 

 

 

  • Q-codes have been assigned to previously approved CAR T cell therapies; their descriptions include leukapheresis and dose preparation procedures1
  • Newly approved biologics, including CAR T cell therapies, will not initially have unique HCPCS codes; miscellaneous HCPCS codes may be reported until a unique HCPCS code is assigned by CMS


Hospital Revenue Codes

 

 

  • CAR T-specific revenue codes became effective in 20192
  • Payer requirements for inpatient/outpatient hospital facilities may vary


ICD-10-PCS Codes

 

 

  • CAR T-specific ICD-10-PCS codes became effective in 20173
  • Starting in 2020, CMS will assign unique ICD-10-PCS codes for each CAR T product4
  • CAR T-specific ICD-10-PCS codes were updated, effective October 1, 20213
  • Payer requirements for inpatient hospital facilities may vary

 


CPT® Codes*

 

 

  • CAR T-specific CPT Category III codes became effective in 20191,2
  • CMS requires physicians and providers to bill these CAR T-specific CPT Category III codes2; private payer policies may vary
  • CPT Category III codes generally do not have assigned relative value units and may not be payable5

 

Coding & Billing Requirements by Payer Segment


Medicare Fee-for-Service (FFS)

 

 


Medicare Advantage (MA) Plans

 

 

  • Billing requirements may vary by payer


Commercial Plans and Other Payers

 

 

  • Billing requirements may vary by payer

*CPT codes, descriptions, and other data only are copyright 2021 American Medical Association. All rights reserved. Applicable FARS/HHSAR apply.

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CAR=chimeric antigen receptor; CMS=Centers for Medicare and Medicaid Services; CPT=Current Procedural Terminology; FARS/HHSAR=Federal Acquisition Regulation Supplement/Health and Human Services Acquisition Regulation; HCPCS=Healthcare Common Procedure Coding System; ICD-10-PCS=International Classification of Diseases, Tenth Revision, Procedure Coding System; R/R=relapsed or refractory.

CAR T CELL THERAPY RESOURCES

PRODUCT-SPECIFIC INFORMATION AND CODES

For the treatment of:

  • R/R large B-cell lymphoma (R/R LBCL)
  • R/R follicular lymphoma (R/R FL)

For the treatment of:

  • R/R multiple myeloma (R/R MM)

This information is provided for educational purposes only. Bristol Myers Squibb cannot guarantee insurance coverage or reimbursement. Coverage and reimbursement may vary significantly by payer, plan, patient, and setting of care and is subject to frequent change. It is the sole responsibility of the healthcare provider to select the proper codes and ensure the accuracy of all statements used in seeking coverage and reimbursement for an individual patient.

References

  1. Centers for Medicare & Medicaid Services. Fed Regist. November 16, 2021:86(218):63458-63998.
  2. Centers for Medicare & Medicaid Services Medicare Learning Network. Chimeric antigen receptor (CAR) T-cell therapy revenue code and HCPCS setup revisions. Published March 17, 2022. Accessed October 20, 2023. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19009.pdf
  3. Centers for Medicare & Medicaid Services. Fed Regist. 2021;86(154):44774-45615.
  4. American Medical Association. CPT Category III Codes. Updated June 30, 2023. Accessed October 20, 2023. https://www.ama-assn.org/system/files/cpt-category3-codes-long-descriptors.pdf 
  5. Centers for Medicare & Medicaid Services. Medicare claims processing manual. Chapter 32. Published June 29, 2023. Accessed October 6, 2023. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf
  6. Centers for Medicare & Medicaid Services. Transmittal 11179. Published January 12, 2022. Accessed October 6, 2023. https://www.cms.gov/files/document/r11179otn.pdf
  7. Centers for Medicare & Medicaid Services. Transmittal 11774. Published December 30, 2022. Accessed October 19, 2023. https://www.cms.gov/files/document/r11774cp.pdf