Gastroenterology Coding Alert

Question: Our physician recently performed the infusion of two anti-neoplastic substances for a patient. I am getting confused about the use of the codes and add-on codes that I have to use to report the infusion procedures? Should I report the primary code (96413) for each substance or report it only once for the session?

Minnesota Subscriber

Answer: When reporting an infusion of any substance for chemotherapy, you will have to report the initial one hour of infusion with 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). You’ll use this code only once per patient unless the two substances were provided during two different sessions of administration on different days.

If the administration of the same substance was continued beyond the first hour of administration, you’ll have to report the administration using the add-on code +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]). You will report one unit of +96415 for every additional hour of administration. As per CPT® time rules, you report +96415 “for infusion intervals of greater than 30 minutes beyond 1-hour increments. So, if the time spent in the infusion beyond the first hour of administration is one and a half hours, you report two units of +96415.

For the second substance, you report the first hour of administration with the add-on code +96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion [different substance/drug], up to 1 hour [List separately in addition to code for primary procedure]). For the administration of the second substance beyond the first hour of administration, you’ll again go back to reporting +96415. For example, if your clinician administered the second substance for two hours, you’ll report +96417 for the first hour and +96415 for the additional hour of administration.

Red flag: If your clinician also provided hydration during the infusion, you’ll have to report this with the add-on code +96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]) for every hour of hydration administered. You will have to note that you cannot use 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) for reporting hydration with a concurrent infusion.

Don’t forget: You will have to report the supply of the substances used for the infusion separately using the appropriate HCPCS J code. Note that these J codes are billed in terms of number of units used for the infusion and not one unit for the entire vial. For example, if a 100-mg vial of Remicade was used, you report J1745 (Injection infliximab, 10 mg) for every ten milligrams used. So, you report ten units (J1745x10) for the entire 100mg vial of Remicade infused.