07/15/2026

ASK MSHO

July 2026 Frequently Asked Questions

Question:

Can you please provide the applicable BCBSM/BCN policy outlining how manufacturer copay assistance is handled?

Our understanding is that some employer-sponsored plans utilize copay accumulator or copay maximizer programs, which may allow manufacturer assistance to reduce the cost of the medication but may not credit the assistance amount toward the member's deductible or out-of-pocket maximum. Other plans may apply these amounts differently depending on the group's benefit design.  

Answer:

Manufacturer copay assistance for these specific groups:

1. Counts toward the member's deductible? No - Copay assistance does not count toward the member's deductible.
2. Counts toward the member's out-of-pocket maximum? No - Copay assistance does not count toward the member's OOP.
3. Is subject to any accumulator or maximizer program? No 

Question:

When can hydration (96360/96361) be billed in an oncology infusion encounter?

Answer: 

Hydration can be billed only when medically necessary and when it meets the CPT time threshold:

• 96360 requires 31 minutes or more of hydration infusion.
• 96361 is used for each additional hour beyond the initial 31 minutes.

Hydration cannot be billed:

• When it is used solely to keep the line open
• When it runs concurrently with chemotherapy or therapeutic infusions
• When documentation does not clearly support medical necessity (e.g., dehydration, renal protection, pre‑treatment hydration protocols)

Documentation must include: start/stop times, fluid type, medical necessity, and infusion rate.

Question:

How do you code a visit when the patient has an active primary cancer and documented metastasis?

Scenario: A patient with active right‑sided breast cancer presents for infusion of systemic therapy. The oncologist documents metastatic disease to bone. Both the primary and secondary cancers are actively being treated.

Answer:

When both the primary malignancy and secondary (metastatic) site are active, ICD‑10‑CM requires coding both conditions, with the primary cancer listed first unless the encounter is solely for treatment of the metastatic site.

Correct ICD‑10 coding for this scenario:

• C50.911 — Malignant neoplasm of unspecified site of right female breast (Primary cancer — still present and under active treatment)
• C79.51 — Secondary malignant neoplasm of bone (Documented metastasis)

Key rules billers should remember:

• Code the primary malignancy when it is still present and being treated.
• Code the secondary site(s) whenever metastasis is documented.
• If the encounter is specifically for treatment of the metastatic site, list the metastatic code first.
• Never use Z85.x (personal history of cancer) when the cancer is still active — even if metastatic.