Oncology & Hematology Coding Alert

Your guide to the correct code is the site, not the duration, of chemotherapy.

When your oncologist prescribes intracavitary chemotherapy, which involves administering a chemotherapeutic agent directly into a body cavity, you’ll need to understand where the therapy was given and what were the steps in the service. Here is how to code services accurately, particularly in situations when the chemotherapy is administered into the pleural and peritoneal cavities.

1. Check the Route of Administration

You should first confirm that the site chosen for drug administration is the pleural or peritoneal cavity.

Pleural: The appropriate code for pleural chemotherapy is 96440 (Chemotherapy administration into pleural cavity, requiring and including thoracentesis). Your clinician may administer chemotherapy in the space between the lung and its lining, i.e. pleural cavity, to control accumulation of cancerous fluid in this space and prevent pleural effusions. This form of therapy is typically performed to provide symptom relief.

Example 1: You may read that in a patient who presented with breathlessness and a diagnosis of lung cancer, your physician inserted a chest tube into the pleural space to drain the fluid from that space (thoracentesis). Your physician then used the same tube to administer chemotherapy. This describes intrapleural administration of chemotherapy, so you report 96440.

Documentation tip: Watch out for terms like ‘sclerosis’ or ‘pleurodesis’ in the procedure notes as clues that the oncologist administered intrapleural chemotherapy. The sclerosis is desirable as it prevents the fluid from accumulating again. Simple drainage of the fluid results in recurrences.

Peritoneal: When reporting peritoneal chemotherapy, choose 96446 (Chemotherapy administration into the peritoneal cavity via indwelling port or catheter). When chemotherapy is administered into the peritoneal cavity, the pharmaceutical agents are introduced into the membrane that lines and supports the abdominal organs.

Example 2: You may read that your physician placed a catheter through the abdominal wall to drain the abdominal cavity. Similar to pleural cavity therapy, the catheter will also be the port for administering the chemotherapy. You may further read that your physician changed the patient’s position a few times to aid the movement of medication. Your physician may or may not drain the chemotherapeutic agent after a few hours. In this example, you would report code 96446.

2. Ignore Duration of Infusion When Choosing Code

Your oncologist may administer the chemotherapy into the pleural or peritoneal cavities over a few hours. However, the code definitions of 96440 and 96446 are not based on the number of hours it requires to perform the procedure. This is an important difference from the IV chemotherapy codes you may be more accustomed to reporting where determines correct coding of the administration.

Example: You may read that your oncologist administered intraperitoneal chemotherapy (single chemotherapy drug) for three hours. In this case, you should report one unit of the administration code, 96446. Reporting one unit per hour, for a total of 3 units, is not correct.

Caveat: CMS has a Medically Unlikely Edit (MUE) of 1 for both 96440 and 96446. That means that if you report more than one unit of either code, Medicare will deny that line item.

3. Identify the Inclusive Services for 96440

The definition of intrapleural code 96440 includes four words you can’t afford to miss: requiring and including thoracentesis. This phrase tells you that 96440 requires thoracocentesis, i.e. the insertion of the chest tube to aid the removal of fluid.

Because the code both requires and includes thoracentesis, you do not report the chest tube drainage of fluid separately from the intrapleural administration of drugs. Correct Coding Initiative (CCI) edits will help keep your coding on track. CCI bundles thoracentesis codes 32554 (Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance) and 32555 (Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance) into 96440. Although you could override these edits using a modifier, it would be inappropriate to do so when the physician performed the thoracentesis in conjunction with the chemotherapy administration.

4. Confirm Permanent Catheter for 96446

You report code 96446 only when your oncologist uses a permanent catheter to administer the chemotherapy planned. Do not report 96446 when your oncologist uses temporary single use catheters. The code descriptor clearly specifies ‘indwelling port or catheter.’

Helpful: Placing a permanent catheter involves tunneling through the subcutaneous space. Some catheters have a life of three to five years. To administer the chemotherapy, the provider will locate the catheter under the skin and use a needle to introduce the drug. You can look for terms like ‘Tenckhoff catheters,’ silicone tubes,’ or ‘port-a-cath’ in the clinical note to help identify permanent catheters.

Caution: You should not report 96446 when your oncologist participated in an operative encounter that involved providing intraperitoneal heated chemotherapy. For intraoperative intraperitoneal heated chemotherapy (IPHC or HIPEC) that is a planned and integral part of the procedure, the most appropriate code is 96549 (Unlisted chemotherapy procedure), according to CPT® Assistant (December 2010). IPHC takes place near the end of a surgical session in which a surgeon removes tumors from the abdominal cavity. The physician allows a warm chemotherapy solution to sit in the abdominal cavity and then drain. The temporary nature of the intraperitoneal catheter used for IPHC is what tells you 96446 is not appropriate for IPHC.

5. You Can Bill for Facility Setting

Unlike other infusion codes, you can report intracavity chemotherapy codes 96440 and 96446 when your physician performs the service in a hospital. According to the CPT® guidelines, “Codes 96360-96379, 96401, 96402, 96409-96425, 96521-96523 are not intended to be reported by the physician in the facility setting.” This is because other infusions are provided by the nursing staff and the hospitals claim the reimbursement. However, even physicians can bill for the for the intracavity chemotherapy codes 96440 and 96446, which are not included in that guideline.