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Effective Date:

a)This policy will apply to all services performed on or after the above revision date which will become the new effective date.

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b)For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)les-grizzlys-catalans.org covers infusions of medications in participating physicians’ offices, participating infusion centers, and participating hospital outpatient departments.

2)This policy restates rules that are present in the national standard coding books about what services are included in the infusion charges.

Medical Statement

1)The following wording appears in the CPT book in the general description of “Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy)” and again in the general description of “Chemotherapy Administration”

a)“If performed to facilitate the infusion or injection, the following services are included and are not reported separately:

i)“Use of local anesthesia

ii)“IV start

iii)“Access to indwelling IV, subcutaneous catheter or port

iv)“Flush at conclusion of infusion

v)“Standard tubing, syringes and supplies.”

2)In view of this definitional statement, charges for syringes, needles, tubing, infusion sets and supplies will not be paid by les-grizzlys-catalans.org, as the pricing for the infusions clearly is intended to cover these items.

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Codes Used In This BI:

A4206

1 CC sterile syringe&needle
A42072 CC sterile syringe&needle
A42083 CC sterile syringe&needle
A42095+ CC sterile syringe&needle
A4210Nonneedle injection device
A4211Supp for self-adm injections
A4212Non coring needle or stylet
A421320+ CC syringe only
A4215Sterile needle
A4216Sterile water/saline, 10 ml
A4217Sterile water/saline, 500 ml
A4218Sterile saline or water
A4220Infusion pump refill kit
A4221Maint drug infus cath per wk
A4222Infusion supplies with pump
A4223Infusion supplies w/o pump
A4230Infus insulin pump non needl
A4231Infusion insulin pump needle
A4232Syringe w/needle insulin 3cc
96360Hydration iv infusion init
96361Hydrate iv infusion add-on
96365Ther/proph/diag iv inf init
96366Ther/proph/diag iv inf addon
96367Tx/proph/dg addl seq iv inf
96368Ther/diag concurrent inf
96369Sc ther infusion up to 1 hr
96370Sc ther infusion addl hr
96371Sc ther infusion reset pump
96372Ther/proph/diag inj sc/im
96373Ther/proph/diag inj ia
96374Ther/proph/diag inj iv push
96375Tx/pro/dx inj new drug addon
96376Tx/pro/dx inj same drug adon
96379Ther/prop/diag inj/inf proc
96401Chemo anti-neopl sq/im
96402Chemo hormon antineopl sq/im
96405Chemo intralesional up to 7
96406Chemo intralesional over 7
96409Chemo iv push sngl drug
96411Chemo iv push addl drug
96413Chemo iv infusion 1 hr
96415Chemo iv infusion addl hr
96416Chemo prolong infuse w/pump
96417Chemo iv infus each addl seq
96420Chemo ia push tecnique
96422Chemo ia infusion up to 1 hr
96423Chemo ia infuse each addl hr
96425Chemotherapy infusion method
96440Chemotherapy intracavitary
96446Chemotx admn prtl cavity
96450Chemotherapy into cns
96521Refill/maint portable pump
96522Refill/maint pump/resvr syst
96523Irrig drug delivery device
96542Chemotherapy injection
96549Chemotherapy unspecified
Limits Intentially left empty Reference Intentially left empty Application to Products This policy applies to all health plans administered by les-grizzlys-catalans.org, both those insured by les-grizzlys-catalans.org and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by les-grizzlys-catalans.org. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific les-grizzlys-catalans.org EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: les-grizzlys-catalans.org reserves the right to alter, amend, change or supplement benefit interpretations as needed.