Ask a Rev Cycle Expert: Injection Procedure for C9094 Sutimlimab-jome?
Question:
The drug ENJAYMO™ has been approved by the U.S. Federal Drug Administration (FDA) and assigned to Healthcare Common Procedure Coding System (HCPCS) C9094 Inj, sutimlimab-jome, 10 mg. The drug has been ordered by an oncologist for Cold Agglutinin Disease. What would be the appropriate administration code for the first hour of administration, Current Procedural Terminology (CPT®) code 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug or 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour?
Answer:
According to the labeling information, ENJAYMO™ is used to decrease the need for red blood cell transfusion due to hemolysis. Because the drug does not fall into one of the categories for highly complex administration, such as requiring additional staff training or competencies, the recommended Current Procedural Terminology (CPT®) code for the first hour is code 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.
You may wish to verify with the payer which administration code is acceptable to them, as payers create their own policies regarding which set of drug administration codes they will use. Because a longer period of post-administration monitoring is necessary, it is possible that a payer may allow for the chemotherapy administration codes.
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