Access & Reimbursement Support

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 may be 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.

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 the patient’s condition, provided services, payer-specific requirements, and selected site/setting of care. It is critical for treatment centers 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 cell therapy-specific revenue codes became effective in 20192
  • Payer requirements for inpatient/outpatient hospital facilities may vary
ICD-10-PCS Inpatient Procedure Codes
  • CAR T cell therapy-specific ICD-10-PCS codes became effective in 20173
  • Starting in 2020, CMS will assign unique ICD-10-PCS codes for each CAR T cell therapy product4
  • Payer requirements for inpatient hospital facilities may vary
CPT® Codes
  • CAR T cell therapy-specific CPT Category III codes became effective in 20191,2
  • Payer requirements for reporting CPT Category I vs CPT Category III codes by outpatient hospital facilities and physician practices may vary
  • CPT Category III generally does 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

Starting in January 2021 (CAR T cell therapy is paid by MA plans):

  • Billing requirements may vary by payer
Commercial Plans and Other Payers
  • Billing requirements may vary by payer

Visit the Resource Library for informative downloadable tools.


Downloadable resource

CAR T cell therapy claim submission checklist

Product-Specific Resources

For product-specific resources, click here.

CAR=chimeric antigen receptor.

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 may be 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. CMS. Fed Regist. November 12, 2019;84(218):61142-61492.
  2. CMS. Chimeric antigen receptor (CAR) T-cell therapy revenue code and HCPCS setup revisions. MLN Matters SE19009. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE19009.pdf. Accessed June 22, 2020.
  3. CMS. Fed Regist. September 18, 2020;85(182):58432-59107.
  4. CMS. FY 2021 IPPS Final Rule Tables. https://www.cms.gov/medicare/acute-inpatient-pps/fy-2021-ipps-final-rule-home-page. Accessed September 11, 2020.
  5. AMA. CPT Category III Codes. https://www.ama-assn.org/system/files/2020-12/cpt-category3-codes-long-descriptors.pdf. Accessed February 10, 2021.