If you are a physician that accepts patients with Anthem BCBS plans then this blog post is for you.
Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression. Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.
There are 2 ways physicians can code the administration of this drug:
Option 1 (Professional Services) – The physician buys the drug and administers it to the patient as well as provides the observation services- Anthem BCBS of California will NOT cover the drug itself or the post administration observation. Instead physicians should use the 2 following codes:
|G2082||Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.|
|G2083||Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.|
Option 1 Outpatient Hospital – the facility is allowed to bill codes G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. Anthem BCBS of California will not reimburse a separate professional claim with code G2082 and G2083.
Option 2: The drug is obtained through a pharmacy. Pharmacy bills the code S0013 – Esketamine, nasal spray, 1 mg.
Post-administration observation: if physician falls into the option 2 category then the physician is allowed to bill the following code:
|99202 – 99205||Office or other outpatient visit for the evaluation and management of a new patient|
|99212 – 99215||Office or other outpatient visit for the evaluation and management of an established patient|
|99417||Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes|
In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding. Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.
Please remember that codes exist but that doesn’t mean that all of them will be reimbursed. In order to reduce denials and get your claims paid please follow the reimbursement policy of a specific Insurance Payer.
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