Revenue Cycle Insider

Question: Our providers are trying to bill CPT^® code 38228, and the claims are continuously getting denied by all insurance companies. Can you provide guidance on how to get this code covered?

AAPC Forum Participant

Answer: The answer to this question, according to Medicare, depends on when and where the therapy is being administered and the way that it is billed. Private payers, of course, will have different guidelines.

First, for Medicare, you should make sure you are using the correct code to bill chimeric antigen receptor (CAR) T-cell therapy administration. This will depend on the date of service as, on January 1, 2025, CPT^Ò updated its (CAR) T-cell therapy codes, replacing four Category III codes with four new Category I codes as follows:

• 38225 (Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day) replaced Category III code 0537T
• 38226 (Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (eg, cryopreservation, storage) replaced Category III code 0538T
• 38227 (Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration) replaced Category III code 0539T
• 38228 (Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous) replaced Category III code 0540T

Then, assuming you are billing 38228 after January 1, 2025, you will need to make sure you are billing the service per Medicare national coverage determination (NCD) 110.24, which also became effective January 1, 2025. As outlined by Medicare Administrative Contractor (MAC) Novitas Solutions, Medicare will only pay for 38228 in Part A and B when administered in outpatient settings, and not in an ambulatory surgery center (ASC). Additionally, Medicare will only pay for the code when the line item has modifier KX (Requirements specified in the medical policy have been met) appended.

In addition, per AHA HCPCS Coding Clinic Vol. 25, No. 1 (2025), you may only bill 38228 for administration and 38225 for collection and handling once per day. As a part of the therapy administration, you cannot separately report fluids “used to administer the cells or incidental hydration,” but you may report “unrelated administration of medications or hydration services” separately providing you append modifier 59 (Distinct procedural service) to those services, according to Coding Clinic.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC