Academy Exchange

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  • 1.  Cabenuva Billing

    Posted 06-14-2021 13:28

    Writing from a Health System Owned Specialty Pharmacy.  We have implemented Cabenuva at our hospital system, with our pharmacy acting as a "hub"; we complete benefit investigation, prior authorization, calling prescription for oral lead in to Theracom Pharmacy, as well as the coordination of getting medication to clinic for nurse administration.   Some claims are payed under pharmacy benefits, some medical benefits.  If pharmacy benefits, we fill Cabenuva at the specialty pharmacy and "clear bag" to the clinic .  If medical benefits will be paying, then it is a "buy and bill" from the infusion pharmacy. 

    Currently hospital is NOT getting paid for ADMINISTRATION of Cabenuva.  We have been using CPT codes 96372 (Ther/proph/diag inj, sc/im), as well as 99211 (office or other outpatient visit for the E&M of an established patient, typically 5 mins). Neither are being reimbursed. 

    Hoping for any guidance or feedback from the community.  

    Thank you in advance, 

    Diana Gabelman, PharmD, CSP, AAHIVP  |  Specialty Pharmacy Clinical Coordinator
    The MetroHealth Systems  |  9885 Rockside Rd Ste. 157 | Valley View, OH  44125
    p: (216) 957-6337 option 3  |  f: (216) 957-4788  |