Oncology & Hematology Coding Alert

Locate the cavity and ignore time of infusion.

Chemotherapy procedures are routine in any oncology practice. Coding for chemotherapy is not limited to IV chemotherapy. You have discrete codes for chemotherapy that your physician administers into cavities. If you apply all rules for IV chemotherapy to intracavity chemotherapy you will run into trouble. The two are absolutely distinct sites and routes. Here is how you confirm the services for intracavity chemotherapy and how they clearly differ from IV chemotherapy.

Catch the cue:  Before you can look for intracavity codes, you must spot specific terms in the procedure note helping to confirm the route of administration. For example, terms like ‘sclerosis’ or ‘pleurodesis’ suggest that your oncologist administered intrapleural chemotherapy. The sclerosis is necessary to prevent the pleural fluid from accumulating. Only drainage of the fluid results in frequent recurrences.

1. Route is Your First Key

For intracavity chemotherapy, the first step is to find where the chemotherapy was administered. “Information contained in the clinical note will confirm the ‘cavity’ targeted for the administration of chemotherapy,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services, LLC (“PERCS”), a division of Pinnacle Healthcare Consulting, CO. One of the most common sites for intracavity chemotherapy are the pleural or peritoneal cavities.

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. in the pleural cavity, to control accumulation of cancerous fluid in this space and prevent pleural effusions. This form of therapy is typically performed to provide symptomatic relief.

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.

Other sites: For intrathecal chemotherapy, you submit code 96450 (Chemotherapy administration, into CNS [e.g., intrathecal], requiring and including spinal puncture). The code 96542 (Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents) implies a subarachnoid injection and the code 51720 (Bladder instillation of anticarcinogenic agent [including retention time]) implies chemotherapy into the bladder cavity. 

Follow these examples:  You may read that your physician inserted a chest tube into the pleural space to drain the accumulating fluid and then used the same tube to administer chemotherapy. This describes intrapleural administration of chemotherapy (96440).

Similarly, your physician may insert a catheter through the abdominal wall to drain the abdominal cavity and use the port for administering the chemotherapy. Your physician changes the patient’s position a few times to aid the movement of medication in the peritoneal cavity. Your physician may or may not drain the chemotherapeutic agent from the abdominal cavity after a few hours.

Report unique procedures as unlisted: You submit code 96549 (Unlisted chemotherapy procedure) for procedures like intraoperative intraperitoneal heated chemotherapy (IPHC). In this procedure, your physician may administer the chemotherapy after the tumor has been removed from the abdominal cavity. Your physician will administer the chemotherapy solution at the end of the surgical session and will allow the warm chemotherapy solution to sit in the abdominal cavity and subsequently drain it.

“Submit code 96549 anytime your physician performs a chemotherapy procedure that does not have a specific code,” says Leah Fuller, CPC, Associate Consultant, Pinnacle Enterprise Risk Consulting Services, LLC, CO. “It is also recommended to submit an explanation stating why the unspecified code was chosen over an active CPT^® code as well as attaching a copy of the procedure note.”

When submitting code 96549, make sure you document the procedure details. Per CPT^® guidelines, “a service that is rarely provided, unusual, variable, or new may require a special report. Pertinent information should include an adequate definition or description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.” >

2. Do Not Bill For Access to Cavity

In the procedure note, look for how your physician made his way to the cavity where he instilled the chemotherapy. For this, your physician may or may not use imaging guidance. Your physician may insert a chest tube (thoracocentesis) or may place a catheter into the bladder.

The code descriptor for 96440, for administration of chemo into the pleural cavity, clearly states that a thoracocentesis is required for the procedure and is included in the code (requiring and including thoracentesis). This definition of the code specifically indicates the 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) is inclusive when reporting 96440.

Watch the bundle: Additionally, the Correct Coding Initiative (CCI) edits bundle thoracentesis codes 32554 and 32555 with 96440 and the code definitions indicate it is included. Although you could override these edits using a modifier, for example modifier 59 (Distinct procedural service). “You may not report these codes together when the physician procedure note describes the thoracentesis was performed to administer the chemotherapy into the thoracic cavity after access was obtained,” Loya says.

Similar to chest tubes for thoracocentesis, you may look for catheters when your physician administers chemotherapy in the bladder. When you read your physician used a catheter for bladder chemotherapy, you cannot separately report the catheter insertion with code 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) with 51720 (Bladder instillation of anticarcinogenic agent [including retention time]).

Per CCI, Code 51701 is a column 2 code for 51720. These codes cannot be billed together in any circumstances.

96446 applies to only permanent catheters: The code descriptor for 96446 clearly specifies ‘indwelling port or catheter’ implying that you submit code 96446 only when your oncologist uses a catheter intended to be indwelling and more permanent rather than a temporary single use catheter for the purpose of administering chemotherapy. “A permanent catheter is inserted with the purpose of being left in place for a long period, sometimes up to three to five years. Temporary catheters are typically used once, or for a short period, then removed,” Fuller says.

Catheter clue: 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.>

3. Check Payer Preferences for Supplies

For any of the other commercial payers, it is good to check for the payer’s policy(ies) pertaining to supplies. Your payer may require you mention the specific supplies on the claim. “If your payers accepts, report the supplies with code 99070 (Supplies and materials [except spectacles], provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) unless a more specific code more accurately describes the item used,” Loya says.

Medicare does not make a separate payment for disposable supplies used in the cavity chemotherapy procedures because it considers supply costs covered under chemotherapy administration codes 96400 ─ 96549.>

Check if you can bill for saline: During any of the cavity chemotherapy procedures, your physician may use saline for flushing the access to the cavity or mixing the drugs while administering the chemotherapy into the cavity. In this case, you may count saline as a supply and is not separately reported. However, if you read that your physician used the saline to hydrate the patient, the saline could be reimbursed by both Medicare and other commercial payers. Submit codes J7030 (Infusion, normal saline solution, 1000 cc) ─ J7050 (Infusion, normal saline solution, 250 cc). “You select from these codes depending upon the specific size of saline used,” Loya says.

4. You Can Bill for Facility Setting

Cavity chemotherapy differs from that administered as infusions. Unlike other infusion codes, you can report intracavity chemotherapy codes 96440 and 96446 when your physician performs the service in a hospital.

Per CPT^® guidelines, “Codes 96360-96379, 96401, 96402, 96409-96425, 96521-96523 are not intended to be reported by the physician in the facility setting.” 

96440 and 96446 are not part of facility setting guidelines: You can see that the intracavity chemotherapy codes 96440 and 96446, are not included in this CPT^® guideline. The guideline applies to other infusions which are provided by nursing staff. Hospitals claim the reimbursement for these services. In the case of cavity chemotherapy, physicians would submit codes 96440 and 96446.

Say No to E/M codes: You would not routinely separately report an E/M service with cavity chemotherapy codes. For example, if the patient is just in the office for a bladder chemo instillation, you’ll only report 51720. But if your physician documents a separately identifiable E/M service, you should report the appropriate-level E/M code, such as 99213 (Office or other outpatient visit for the E/M of an established patient ...) and append modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show that the office visit was supported as a separate service over and above the pre- and post- operative work for the procedure itself.

5. Time Is Irrelevant In Cavity Chemotherapy

Like IV chemotherapy, cavity chemotherapy may span over a few hours. However, unlike the IV chemotherapy codes, time required for administration is not important. “You will note there is no identification of a time increment in the definition of these codes,” says Loya. “Therefore, the codes for cavity chemotherapy are not based on the number of hours it requires to administer it.”

Example: You may read that your oncologist administered intraperitoneal chemotherapy (single chemotherapy drug) over the course of three hours. In this case, you should report one unit of the administration code, 96446. 

Caution: If you report one unit per hour for 96446 for a total of 3 units, you are not correct. CMS has a Medically Unlikely Edit (MUE) of 1 for both 96440 and 96446. Meaning that if you report more than one unit of either code, Medicare will deny that line item.