Oncology & Hematology Coding Alert

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Justify Why the Infusion Lasts longer

Answer 1: Selection of the correct CPT^® codes to document an infusion service lasting 105 minutes is relatively straightforward. Following CPT^® instructions for time-based coding, which tell you that “a unit of time is attained when the mid-point is passed” and that “an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes),” you’ll use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour and +96415 (... each additional hour (List separately in addition to code for primary procedure)) for the additional 45 minutes beyond the first hour.

However, your documentation will also need to justify why the infusion service lasted longer than the scheduled time. That’s because a payer will want to see that the additional time spent was medically necessary and the infusion time was not extended to increase reimbursement for the service. At a minimum, this means documenting start and stop times and may need information to support the additional time, effort, and resources spent on the patient.

Antibiotic Infusion Makes Things Complicated

Answer 2: Again, selection of the correct CPT^® codes for the infusion is relatively straightforward and will look similar to the previous answer: you’ll use 96413 for the first hour and +96415 for the additional 55 minutes.

The answer gets complicated once the antibiotic infusion is added into the mix. You might be tempted to use +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]) for the service following the CPT^® instructions that accompany the code, which tell you to use +96367 “in conjunction with ... 96413 to identify the infusion of a new drug/substance provided as a secondary or subsequent service after a different initial service is administered through the same IV access.”

However, the antibiotic infusion only lasted 14 minutes, and per the CPT^® section-specific guidelines for the hydration, injection, and infusion services codes, “an infusion of 15 minutes or less” is defined as an “intravenous or intra-arterial push.” This means you should use 96375 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug).

Also, per those same section-specific guidelines, you would report 96375 last in the coding sequence, even though it was the first service administered. The guidelines stipulate that you code first the “key or primary reason for the encounter reported irrespective of the temporal order in which the infusion(s) or injection(s) are administered.” So, the correct coding and sequence in this scenario is 96413, +96415, 96375.

Here’s What to Do for a Malfunction

Answer 3: As the leak occurred after the patient received 10 minutes of the drug, and given that the 10 minutes does not reach the mid-point of the time stipulated by 96413, or 31 minutes, you cannot use this code. However, as the answer to question two points out, the service did last for ten minutes, making it possible for you to document an intravenous push. For an intravenous push of a chemotherapy drug, that means coding 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

If your provider was able to continue the infusion after the malfunction was identified and resolved, then you could possibly code 96413 if the total time reported for the infusion met the time parameters of the code.

Coding tip: No matter which way you code this encounter, you should report the entire amount of paclitaxel your patient received with code J9267 (Injection, paclitaxel, 1 mg) with a unit for each mg of paclitaxel administered. It is also important to note that paclitaxel medication waste would not be billed as this product is typically supplied in a multi-dose vial.

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