Oncology & Hematology Coding Alert

If you assume that intra-arterial (IA) infusions follow the same rules as IV infusions, you only correct for part of the time. The rules do differ in some cases. Dig into these liver cancer scenarios and see how you fare.

The codes: CPT^® 2020 lists four codes under “Intra-Arterial Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration:”

• 96420 (Chemotherapy administration, intra-arterial; push technique)
• 96422 (… infusion technique, up to one hour)
• +96423 (… infusion technique, each additional hour)
• 96425 (… infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump).

Zoom in on ICD-10-CM Metastasis Rule to Prevent Denials

Payers are most likely to cover IA chemo, which is not as common as IV chemo, for liver cancer as well as colon cancer metastatic to the liver.

You should report primary liver cancer with C22.0 (Liver cell carcinoma). The most common type of primary liver cancer is hepatocellular carcinoma, experts say. Other types include cholangiocarcinoma, hepatoblastoma and angiosarcoma.

ICD-10-CM classifies colon cancer metastatic to the liver under C78.7 (Secondary malignant neoplasm of liver and intrahepatic bile duct).

According to official ICD-10-CM guidelines, when a patient is admitted because of a primary neoplasm with metastasis, and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. You should assign the primary malignancy with an additional code.

Translation: Report secondary neoplasm code C78.7 when a patient with colon cancer metastatic to the liver presents for secondary liver neoplasm treatment only. If no further details regarding the specific part of the colon are documented, you would report C18.9 (Malignant neoplasm of colon, unspecified) as the additional diagnosis for the primary malignancy.

96420: Apply -Push- Definition to IV and IA

Term: CPT^® guidelines indicate that the same definition of “push” applies to both IV and IA administration:

a) “an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient”

OR

b) “an infusion of 15 minutes or less.”

When your provider documents an IA chemotherapy push, you should report 96420.

Example A: A nurse administers a 25-minute IA chemotherapy injection. She is present the entire time and observes the patient throughout the injection time. You should report 96420.

Example B: A nurse administers a five-minute IA chemotherapy infusion. You should report 96420.

96422/96423: Minute 31 Is the Coding Key

When the patient receives an IA chemotherapy infusion lasting more than 15 minutes, you should report 96422 for the first hour, according to the code’s descriptor.

Example: The nurse administers a 45-minute IA chemotherapy infusion. You should report 96422.

Don’t miss: You should use add-on code 96423 to report each additional infusion intervals more than 30 minutes beyond a one-hour increment.

That means that if the total IA infusion time is one hour and 30 minutes, you should report only 96422. You should not report 96423 along with 96422 because the total time is only 30 minutes — not “more than 30 minutes” — beyond a one-hour increment.

Test yourself: Suppose a nurse administers a 5-hour, 17-minute IA chemotherapy infusion. Determine which CPT^® codes and how many units you should report.

Solution: Report one unit of 96422 for the first hour. Report four units of 96423 for hours two through five. You should not report the remaining 17 minutes separately because they do not meet the «more than 30 minutes» requirement for reporting an additional 96423 unit.

Helpful: These timing rules for IA infusion codes 96422 and 96423 are the same as those for the IV infusion codes you use more commonly, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and +96415 (… each additional hour).

96425: Verify Pump Use First

Code 96425 describes prolonged infusions longer than eight hours that require portable or implantable pump use.

You may report this code regardless of whether you own or bill for pump rental because this code covers infusion initiation rather than the physical pump.

When the providers offer refilling or maintenance of an IA portable pump or implantable infusion pump or reservoir, you should choose the appropriate code from 96521-96523, the same codes you would use if the patient received IV pump delivery.

No Need to Determine ‘Initial’ IA Code

Correctly identifying whether you should report an “initial” or “sequential” code is one of the more complicated aspects of reporting IV services such as hydration, chemo and non-chemo therapeutic infusions.

Why: The order in which the provider administers IV infusions or injections during a patient encounter does not dictate which service you report as initial, says Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president and CEO of SLG, Inc. Consulting in Raleigh, North Carolina.

In a physician office, reported for professional services, “The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur,” says Chapter 12, 30.5E, of the Medicare Claims Processing Manual.

Example: A patient presents to the office for IV chemotherapy treatment — the key reason for the encounter. The provider performs a therapeutic, non-chemotherapy IV infusion or injection (such as, antibiotics, steroidal agent, antiemetics, narcotics, etc.) first. You should report initial IV chemo code 96413 and sequential IV infusion code +96367 (Intravenous infusion, for therapy, prophylaxis or diagnosis [specify substance or drug]; additional sequential infusion of a new drug/substance, up to 1 hour) (List separately in addition to code for primary procedure)).

Watch out: You won›t find “initial” or “sequential” IA chemotherapy codes in CPT^®.

That means that unless your payer instructs you otherwise in writing, you may report an IA infusion with 96422 and an initial IV code, such as 96365 (Intravenous infusion, for therapy, prophylaxis or diagnosis [specify substance or drug]; initial, up to 1 hour) on the same day for the same patient.