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When is insulin administration integral to a service?

APCs Weekly Monitor, January 23, 2009

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Q. Can we report subcutaneous insulin injections with CPT code 96372 (therapeutic, prophylactic or diagnostic injections, subcutaneous or intramuscular)?

A belief exists that hospitals shouldn’t report the administration because insulin is a self-administered drug. However, I have never heard of this before and cannot find anything that addresses this issue further.

A: Injectable drugs that are integral to outpatient treatment paid under OPPS, even if they are considered to be self-administered, are normally covered. However, some FIs and MACs only consider insulin to be integral to treatment if the patient is in a diabetic coma based on a section from the old paper-based Hospital Manual (Pub. 10) retired in October 2003. Pub 10 is no longer effective guidance, but policies that your FI/MAC has not retired continue to apply to your facility.

The drug administration service would not be medically necessary for an injectable self-administerable drug. Therefore, it’s vital that the hospital first verify its FI/MAC policy that describes when insulin is integral to outpatient treatment and therefore considered covered part of the treatment. Hospitals also should verify their FI/ MAC policy on drug administration services for drugs that are not covered.

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