Oncology & Hematology Coding Alert

Route of administration guides you to right code.

The Current Procedural Terminology (CPT^®) has clear information and directions for reporting the administration of chemotherapy— which means you should have no trouble following it. Here is how you can validate the correct coding of your chemo administration.

Confirm Route of Administration

When reporting injections and infusions for administration of chemotherapy, the first step is to confirm how the injection was given (i.e., if your physician adopted an intramuscular (IM), subcutaneous (SC), or intravenous (IV) route).

Confirm hormonal vs. non-hormonal for SC and IM routes of administration: If read the physician ordered and the clinical staff delivered a subcutaneous or intramuscular route for chemo administration, you report code 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) or 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic). Therefore, you must determine if the compound administered was a non-hormonal or hormonal substance.

Example: When you read that your physician used GnRH or the analogs, including but not limited to J9217 (Leuprolide acetate [for depot suspension], 7.5 mg), for the treatment of cancer, you may bill the drugs only with 96402. While this substance is typically considered a hormonal antineoplastic and is located in the chemotherapy section of the HCPCS book, you should always verify that the third party payor you are billing conforms to this coding rationale. Policies and requirements may still vary.

Count lesions for intralesional route: When reporting an intralesional administration of chemotherapy, you need to check how many lesions your physician treated. For up to 7 lesions, code 96405 (Chemotherapy administration; intralesional, up to and including 7 lesions) is appropriate.  For more than seven lesions, look at code 96406 (Chemotherapy administration; intralesional, more than 7 lesions).

Example: Your physician may be treating a Kaposi sarcoma by injecting vinblastine into four brown blotches in the skin. In this case, you report code 96405. Report appropriate units of J9360 (Injection, vinblastine sulfate, 1 mg).

Check drugs for IV push technique: The choice of codes for IV push technique is again governed by the drugs therapy course the physician orders for administration. If the therapy requires the initial drug, is an IV push, you report code 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug). If the therapy requires the drug is given second in the course on the date of service, for subsequent push of the same substance or administration of another drug, you report code +96411 (Chemotherapy administration; intravenous, push technique, each additional substance/drug [List separately in addition to code for primary procedure]).

Example: In a patient with multiple myeloma who received an IV push of bortezomib, you submit code 96409. According to total dose of bortezomib, you also report appropriate number of units of HCPCS code J9041 (Injection, bortezomib, 0.1 mg).

Watch time in IV infusions: For IV infusions, the time of the infusion is your guide to the right code. For infusions lasting an hour, submit code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). For every additional hour of infusion, submit code +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]).

Example: In a patient with Ewing’s sarcoma, your physician may administer 1668 mg of cyclophosphamide intravenously over one hour followed by 333.6 mg of mesna. In this case, you report the chemotherapy administration code for the first intravenous infusion. Then you report a single unit of code 96413 for the administration that lasted an hour. Then, report 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 second infusion. If either infusion exceeded 91 minutes, be sure to also report the additional hour(s) with +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]). Don’t forget to report the drug amounts administered. In this case, you will also report seventeen (17) units of J9070 (Cyclophosphamide, 100 mg) for the 1668 mg administered and two (2) units of code J9209 (Injection, mesna, 200 mg) for 333.6 mg of mesna administered.

Check if Modifiers Apply

You may read that the patient returned for another service on the same day, which was separately identifiable, or the patient needed two IV lines. In both these conditions, you can append modifier 59 (Distinct procedural service) to the initial chemotherapy administration code.

Know When You Can Report a Separate E/M Code

When your physician performs a separately identifiable evaluation and management (E/M) service at the same time as the injection, such as an office visit, you can report the second E/M service separately using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Verify the documentation supports both E/M services and the reason for the return of the patient to the office. Your physician has to document at least two (for established patients) or three (for new) of the required elements (history, exam, and medical decision-making) to report an E/M code.

Example: An established patient may visit the physician office for a leuprolide injection and evaluates the patient. During the visit, the physician suspects an active infection for which he may request an X-ray and prescribe an antibiotic. In this case, you can use established patient office visit codes 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) based on what the documentation supports in reporting the physician’s services. You should also append modifier 25 to the 99211-99215CPT^® code when you bill them with 96402. The medication is reported with J9217 (leuprolide) injection.

Report Chemo Codes When Appropriate

Chemotherapy administration codes (96401-96417) apply to parenteral administration of chemotherapeutic agents. However, these are not limited to just agents used in malignancies. The use of these codes also extends to a broader range of agents used in cancer treatment and diagnosis.

You submit these codes for the following:

• Anti-neoplastic agents provided for treatment of noncancer diagnoses, e.g., cyclophosphamide for auto-immune conditions
• Non-radionuclide anti-neoplastic drugs
• Certain monoclonal antibody agents, and
• Other biologic response modifiers. 

Who can administer chemotherapy? The administration of chemotherapeutic agents may be done by:

• A physician, or
• Other qualified health care professional. 

Chemotherapy Administration is Complex

Infusion or administration of chemotherapeutic agents is considered to be complex. This is because of the monitoring of safety parameters that is needed when chemotherapeutic agents are administered.

Chemotherapy services require advanced practice training and competency for staff providing these services. Administration involves planning for preparation, dosage, and proper disposal. Frequent or constant patient monitoring adds to the complexity of these services. Besides these, there is complexity involved in patient education of the therapy, procurement of patient consent, and assessment of the patient’s physical condition before the chemotherapy administration. Hence the services of chemotherapy administration are much beyond those involved in administration of other therapeutic drug agents (i.e., 96360-96379 for therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion).

Remember: The chemotherapy administration codes are inclusive of the preparation of chemotherapy agent(s), highly complex agent(s), or other highly complex drugs.

Check level of complexity: To report infusions that do not require this level of complexity, look to codes
96360-96379. 

Note: You do not submit codes 96401-96402, 96409-96415 when your physician or other qualified health care professional administers the drugs in the facility setting. This is because the hospital or other facility (OPPS or IPPS) payment is included in the facility bill places.

For more on regulations related to billing of chemotherapy administration, refer to the CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual , Chapter 12, Section 30.5.