September 30, 2025
Update: Correct Billing & Payment for CAR T-Cell & Other Immunotherapy Cases
Effective for inpatient (TOB 11X) claims with discharge dates on or after October 1, 2020:
- MS-DRG 018 (Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapies) assigns to cases that include procedures describing CAR T-cell therapies.
- A payment adjustment applies to clinical trial or expanded access use immunotherapy cases where the CAR T-cell and other immunotherapy product isn’t purchased in the usual manner.
- A payment adjustment doesn’t apply when the CAR T-cell therapy product is purchased in the usual manner, but the case involves a clinical trial of a different product.
Effective for claims with discharge dates on or after October 1, 2025, a payment adjustment also applies when the immunotherapy product isn’t purchased in the usual manner, such as provided at no cost.
Use the billing instructions below to ensure you receive the correct payment.
Clinical Trials
When the CAR T-cell and other immunotherapy product isn’t purchased in the usual manner, report:
- Condition code 30
- Value code D4 and the National Clinical Trial (NCT) number
- Revenue code 0891 or 0892 with a covered token charge ($1.00 or less)
- Diagnosis code Z00.6
The Pricer will apply the payment adjustment.
When the CAR T-cell and other immunotherapy product is purchased in the usual manner, but the case involves a clinical trial of a different product, report:
- Condition code 30
- Value code D4 and the NCT number
- Revenue code 0891 or 0892 with covered charges (greater than $1.00)
- Diagnosis code Z00.6
- Billing Note NTE02 (837I electronic claim) or Remarks (Direct Data Entry (DDE) or paper claim): “Diff Prod Clin Trial”
Important: You must report “Diff Prod Clin Trial” verbatim; the Pricer won’t apply the payment adjustment.
Expanded Access
Report the following:
- Condition code 90
- Revenue code 0891 or 0892 with a covered token charge ($1.00 or less)
- Billing Note NTE02 (837I electronic claim) or Remarks (DDE or paper claim): “Expand Acc Use”
The Pricer will apply the payment adjustment.
No Cost
When the immunotherapy product isn’t purchased in the usual manner, such as provided at no cost, report:
- Revenue code 0891 or 0892 with a covered token charge ($1.00 or less)
- Billing Note NTE02 (837I electronic claim) or Remarks (DDE or paper claim): “PROD NO COST”
Important: You must report “PROD NO COST” verbatim; the Pricer will apply the payment adjustment.
Resources
- CR14028
– Continuation of System Changes to Automate Processing of Inpatient Claims for Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapy Cases - CR13926 – Fiscal Intermediary Shared System (FISS) Changes to Automate the Application of Condition Code ZC for Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapy Cases Involving a Clinical Trial of a Different Product
- MM12814 – Inpatient & Long-Term Care Hospital Prospective Payment System: FY 2023 Changes
- MM11879 – Fiscal Year (FY) 2021 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) PPS Changes
- NCD 110.24: CAR T-Cell Therapy Billing Instructions
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