Inpatient Facility Coding & Compliance Alert

Take note: One coding example specifically applies to facilities.

If your facility provides chemotherapy infusion services, take note: 2013 has been a year of change, including nearly half a page of new or revised portions to the chemotherapy administration guidelines in CPT^®. Although a large portion of the guidelines for codes 96401-96549 (Chemotherapy administration …) are marked as revised, only a few changes were made -- but overlooking these could sink your pay for these services.

Biggest shift: The AMA revised the language to clarify that any qualified health care professional (not just a physician) may provide the work or monitoring required. The same revision applies to procedures throughout CPT^® 2013.

Remember: The CPT^® code set is explicitly neutral on stating which provider types are qualified to report a service. That means you should review your specific state scope of practice for each non-physician provider type and review individual payer requirements to determine which providers may perform and bill for specific services. 

Note also that this new language involves mainly the professional coding and billing. The proper application of this new CPT^® guidance on the hospital side is not as clear. For instance, a specially trained chemotherapy nurse may be clinically qualified to administer chemotherapy. However, for the Medicare program this nurse must have direct physician or qualified practitioner supervision in order to report and bill the services.

Don’t Miss a Key Example

Although the chemotherapy-specific guidelines didn’t change much, there is a notable change regarding initial service coding in the 2013 guidelines for “Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.”

The revision updates an example for coding multiple infusions performed at a single encounter that spans multiple dates-of service. The multi-day nature of the example and comments in AMA’s CPT^® Changes 2013: An Insider’s View indicate that the example pertains to facility reporting rather than to a typical office administration. But any coder may be interested to see the concept supported by CPT^® 2013.

2012 statement: The 2012 guidelines indicate that when services extend beyond midnight, the date of service change is like a reset button, allowing you to report an initial infusion code for the first infusion of the new day. The 2012 example states, “a medication was given by intravenous push at 10 PM and 2 AM, as the service was not continuous, both administrations would be reported as an initial service (96374).”

2013 update: In 2013, CPT^® administration guidelines instead indicate that services that extend from one day to the next should be considered a “single encounter” and coded accordingly, says Kelly C. Loya, CPC-I, CHC, CPhT, Director of Enterprise Risk, Internal Audit, and Compliance for Sinaiko Healthcare Consulting Inc., a reimbursement services division of Altegra Health.

The revised 2013 language reads as follows: “a medication was given by intravenous push at 10 PM and 2 AM, as the service was not continuous, the two administrations would be reported as an initial service (96374) and sequential (96376) as: (1) no other infusion services were performed; and (2) the push of the same drug was performed more than 30 minutes beyond the initial administration.”

‘Initial service’ assignment take-away: “Be sure to report an initial service only once over the span of a ‘single encounter’ regardless of the date(s) on which they occurred,” Loya advises. The encounter, rather than the date of service when administrations are given during an overnight stay, determines when an initial administration code can be used.