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March 21, 2012

Information Regarding the Billing and Payment for Administration of PROVENGE®

The Centers for Medicare & Medicaid Services (CMS) had, on Fri Jan 6, 2012, reissued CR 7431, Transmittal 2380, for autologous cellular immunotherapy (PROVENGE®) treatment of metastatic prostate cancer with clarification regarding payment for the administration of PROVENGE and allowing for separate payment for the cost of administration. However, there is an issue in the Medicare claims processing system that is causing claims for administration of PROVENGE® not to be paid separately from PROVENGE®. The Current Procedural Terminology (CPT) code 96365 is bundled when billed with Healthcare Common Procedure Coding (HCPCS) code Q2043. Providers of PROVENGE® may be affected by this situation.

To correct this problem, CMS will update current editing to allow CPT code 96365 to be paid separately when HCPCS code Q2043 is present on claims with dates of service on and after Fri July 1, 2011. CMS has instructed Medicare contractors to adjust claims for dates of service on and after Fri July 1 containing CPT code 96365 that were denied and not paid due to the bundle editing, when brought to their attention. Providers may, beginning Sun Apr 1, request contractors to adjust claims for administration of PROVENGE® that were denied for this reason.

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