CPT® Codes for Outpatient Hospital and Physician Services*
The following CAR T cell therapy-designated CPT Category III codes may be reported for outpatient hospital facility services or physician services associated with Breyanzi. Please note that only one of these CPT Category III codes (CPT code 0540T) is separately payable by Medicare under the Hospital OPPS.15
CMS has not assigned relative value units or APCs to these Category III CPT codes, with the exception of the CPT code 0540T under the OPPS.14,15 As such, they may not be payable by non-Medicare payers.
CMS has instructed MACs that Medicare only covers CAR T therapy when administered in a REMS‑certified healthcare facility. When a facility submits a claim, in order to acknowledge that they are REMS‑certified, the claim must have the KX modifier appended to the CAR T administration code 0540T. In Transmittal 11179 (released in January 2022), CMS clarified that the KX modifier is required for CAR T claims submitted by outpatient hospital facilities (Part A outpatient claims) and physician practices (Part B professional claims).13,17||
*Site/setting-of-care decisions are at the sole discretion of the treating physician.
†See previous section for revenue code descriptions.
‡For Medicare Advantage patients, billing requirements and reimbursement methodology may vary by plan.
§CPT Category III codes 0537T, 0538T, and 0539T can be reported for tracking purposes only, as non-covered charges. For more information, please see Chapter 32 of the Medicare Claims Processing Manual.13
||Once a hospital facility is identified by a MAC as an FDA REMS-approved facility for a particular CAR T cell therapy, the facility is added to a special edit that allows their inpatient and outpatient facility claims to process automatically regardless of whether the KX modifier is present on subsequent claims. This special Medicare edit is not applicable to professional claims billing 0540T. For all Medicare professional claims billing this code, the KX modifier must be present on each CAR T claim.15