We are hearing a lot of buzz about CAR-T but aren’t sure what the coding and reimbursement implications will be?  What do people know? 


  • When there is buzzing, I'd look closely for something that is going to sting you. And billing for CAR-T and not getting paid is a big sting. It is only approved for a very small number of rare conditions so be sure if your docs are talking about it, you do a lot of due diligence. 
  • It is so new and only a few hospitals are approved by the first manufacturer FDA approved which is Novartis and the indications are more for pediatric patients, so this will impact Medicaid and commercial payers.  The cost is $475,000 per dose and for hospitals to obtain correct outlier payments they need to be sure to understand the how the outlier formula is tied to their hospital's cost to charge ratio and to mark-up the item appropriate.
  • There are no perfect codes so be careful if you see guidance suggesting use of existing apheresis, chemotherapy, or stem cell transplant codes. I just finished up some work with the American Society of Blood and Marrow Transplantation (ASBMT) on identifying the most appropriate codes to use and you can find their official position at:

    In the absence of specific codes I would reply on CPT coding instructions which indicate that codes should not be selected just because they are close or approximate a service.  In these cases it would be most appropriate to report unlisted codes. Unlisted codes aren’t very popular, but they exist for a reason and should be used until more specific guidance is released by CPT and/or CMS.

Sign In to comment.