Coding Conundrum: SPRAVATO® (Eskatamine), Part 1

In 2019, The U.S. Food and Drug Administration approved SPRAVATO® (Eskatamine) nasal spray to be used in conjunction with an oral anti-depressant for adults who struggle with treatment-resistant depression (TRD) and/or major depressive disorder (MDD) with suicidal thoughts or actions. Because of risk factors, such as, sedation, disassociation, and respiratory depression, Spravato® must be administered in a certified medical office and the patient must be monitored for a minimum of two hours by a health care provider, which includes pulse oximetry, respiratory status, and blood pressure. At the conclusion of the monitoring period, it is the healthcare provider’s responsibility to determine if and when it is safe for the patient to leave the medical office.

There is a lot of discussion (and discrepancy) around proper code selection for Spravato® treatment. That is why this blog post is coming to you in two parts; in part 1 I will address how to properly code for the drug and administration, while part 2 will concentrate on how to bill for the time spent monitoring patients after drug administration. I will try not to make your head spin with all the coding nuances and scenarios that come into play when trying to determine Spravato® coding, but bear with me as we tackle this beast. Grab a snack and a beverage of choice because this one is a doozy!

First, let’s determine proper code selection for the drug itself. To do so, you need to consider the patient’s insurance, specifically under which benefit Spravato® is covered, medical or pharmacy. From there, you have multiple procurement options, which will affect code selection:

• Medical Benefit
  • Buy and Bill
    • Direct expense to office/provider
    • Provider bills insurance for the drug, administration, and related observation and monitoring services.
  • Risk Evaluation and Mitigation Strategy (REMS)-certified specialty pharmacy via assignment of benefits (AOB)
    • Pharmacy supplied drug, delivered to the administering site, pharmacy to obtain reimbursement under medical benefit.
    • Provider bills insurance company for the administration, and related observation and monitoring services.
  • Pharmacy Benefit
    • Local REMS-certified and/or specialty pharmacy
      • Pharmacy supplied drug, delivered to the administering site, pharmacy to obtain reimbursement.
      • Provider bills insurance company for the administration, and related observation and monitoring services.

Buy and Bill

As previously mentioned above, the buy and bill option results in the provider’s office incurring the cost for procuring the drug. To establish if buy and bill is an option for your practice, confirm your place of service (POS). The Centers for Medicare & Medicaid Services (CMS) maintain POS codes, which are two-digit codes placed on professional claims to indicate the setting in which the service was provided. Typically buy and bill occurs in POS 11, office, instead of POS 19/22, hospital outpatient departments (HOPD), where staff services and supplies are billed out on a facility claim, instead of a professional claim.

If the buy and bill procurement method is utilized, then the final piece of the code selection puzzle will be to look at payer policy. Like many procedural services, payers will often differ in their coding guidance, especially between Medicare and non-Medicare payers. When it comes to Spravato® reimbursement, that is exactly the case.

For Medicare payers, one of the following HCPCS code(s) must be reported:

1. G2082- Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post administration observation.
2. G2083- Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post administration observation.

When reporting Spravato® services to a Medicare payer under the buy and bill procurement option, the drug, administration, and monitoring are all inclusive to G2082/G2083. The obvious difference is in the dosage of the drug administered, whether it be up to 56 mg or greater than 56 mg. Either code would be reported with one unit of service, regardless. While these are designated as Medicare codes, other payers may also accept the G-codes. As always, verifying payer policy is of the utmost importance to ensure a clean claim and timely reimbursement. All in all, shockingly easy, right?!? Well, hold that thought because for non-Medicare payers’ things start to get a little bit more complicated.

For non-Medicare payers that do not accept G2082/G2083, we must go a different route for reporting Spravato®. Again, working under the buy to bill method, you are allowed to bill for all three areas of the service separately, e.g., drug, administration, and monitoring time (monitoring time will be discussed in more detail in part 2).

1. Drug
   • S0013- Esketamine, nasal spray, 1 mg
     • Units dependent on dosage
       • 56mg= 56 units
       • 84mg= 84 units
     • J3490, unclassified drugs
       • Always reported with 1 unit, as unclassified codes are not drug specific.

2. Administration
   • Evaluation and Management (E/M) Codes, 99202-99215
3. Monitoring
   • Prolonged Service Codes, 99417 or G2212
   • Prolonged Clinical Staff Service Codes, 99415/99416

Step one, drug code selection is dependent on payer; either S0013 or J3490 will be required, never both. So, confirm those benefits people!

Step two, drug administration is reported by utilizing office/outpatient E/M codes. Utilizing standard methodology of total time or medical decision-making (MDM) to level your service seems straightforward (no pun intended), but you may not be able to bill the higher level(s) of service you think you can. E/M services are reported for the medical decision-making process on the date of service, so on the date of Spravato® administration, that initial “decision” to treat the patient has more than likely already occurred during a previous visit and cannot be counted again towards the administration visit. We must think about what MDM is medically necessary on the date of the administration, which if the patient is presenting for a planned procedure, probably is not much, because that “work” has already been completed at prior visits. If we determine the E/M based on time, the administration of Spravato® may only take a few minutes, give, or take depending on any additional pre- service work. Taking that into consideration, you may be left with a straightforward, level 2, E/M service, or even a nurse visit, 99211, if clinical staff is performing the service under physician supervision.

REMS-Certified Specialty Pharmacy

Now that you are enlightened on the buy and bill method, let’s discuss proper coding when Spravato® is supplied by a pharmacy. If the patient’s insurance requires obtaining Spravato® through pharmacy benefits, the pharmacy is responsible for obtaining reimbursement for the drug. That is why when administration occurs, the provider cannot bill for the drug itself, as it is already being accounted for. What you are left with for billable services are the administration and the monitoring, both of which basically follow the same rules as mentioned under buy and bill, e.g., E/M for the administration, and possibly prolonged services, or prolonged clinical staff services (discussed in part 2).

The big difference affects Medicare claims for Spravato® under a REMS-certified specialty pharmacy; G2082 and G2083 no longer apply. These two codes include reimbursement for the drug itself, and you cannot claim reimbursement for the drug when it comes from a pharmacy. When this occurs, you will again have to reference your POS, office or HOPD, to ensure proper code submission. If you are in an office setting, POS 11, have a Medicare patient with Spravato® covered under medical AOB or pharmacy benefits, submit an E/M service code for the administration. However, if you are designated as HOPD, POS 19/22, and clinical or ancillary staff are administering Spravato®, you would submit G0463, hospital outpatient clinic visits for assessment and management of a patient, on the facility claim. Professional charges for administration would only apply if the provider directly delivered a service. In an HOPD setting, services provided by clinical or ancillary staff are documented and billed through the facility claim, thus exempting them from individual professional charges.

To wrap up Coding Conundrum: SPRAVATO® (Eskatamine), Part 1, first and foremost, confirm patient benefits. Completing that step will set you on the correct path for accurately reporting Spravato® and its administration. Stay tuned for Coding Conundrum: SPRAVATO® (Eskatamine), Part 2, where I will discuss coding for the 2-hour monitoring period post-administration.