Oncology & Hematology Coding Alert

Keep these rules and definitions close at hand.

Little in oncology coding is more complex than reporting infusions. From understanding how and when you can code hydration services to knowing how to organize all the information to bill infusions accurately, infusion coding is difficult because it has a lot of moving parts.

In her HEALTHCON 2023 presentation, “Infusion Confusion: Learning to Code Complex Infusions,” Kelly Loya, CPC, CHC, CRMA, CPhT, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina, offered several important strategies for coding complex infusions. Here are four of the most important to use whenever you have to code an infusion scenario.

Tip 1: Know the Hierarchies

Loya began her presentation by reminding her audience there is a difference between the coding hierarchies for facilities and code assignment logic for physician offices.

“Facility coders always code the most complex procedure first, beginning with chemotherapy, followed by therapeutic, prophylactic, or diagnostic medication and ending with hydration,” according to Loya.

But nonfacility coders, including coders in physician offices, should begin with the primary reason for the infusion, “though most often, the reason for the encounter is the same as the hierarchy used for facility assignment priority. But the primary reason to assign the initial code must be supported in the medical record,” Loya added.

Tip 2: Understand the Rules

Loya then explained the key rules behind coding each infusion category.

Hydration “may not be reported if administered for under 31 minutes, when running concurrently with anything else, or when it is simply keeping a line functioning to administer other medications,” Loya noted. But hydration can be billed if the provider orders it for a medically necessary reason, such as replacing fluid volumes or as prehydration for certain medications.

Therapeutic, prophylactic, diagnostic administration for non-chemotherapy drugs is coded according to the location, as follows:

• Intravenous infusions/pushes (IV) go directly into the vein.
• Subcutaneous infusions (SQ) are applied under the skin.
• Intra-arterial injections (IA) go directly into the artery.
• Intramuscular injections (IM) go deeper than the subcutaneous skin layer, into the muscles.

Highly complex drugs/biologic agents (chemotherapy) include antineoplastic chemotherapy (nonradionuclide and treatment of noncancerous diagnoses), biological response modifiers (BRM), and monoclonal antibodies (MCA). Per CPT^®, the services require “physician or other qualified health care professional work and/or clinical staff monitoring well beyond that of therapeutic drug agents … because the incidence of severe adverse patient reactions are typically greater.”

Additionally, drug preparation (a.k.a. provision) is included in the pricing for the codes and you should not bill it separately.

Tip 3: Understand the Code Structure/Definitions

Know your code locations: For quick reference, you’ll find the CPT^® infusion administration codes for each category in the following locations:

• Chemotherapy: 96401-96549
• Therapeutic, prophylactic, diagnostic: 96365-96379
• Hydration: 96360-+96361

The codes are broken down into initial, parent codes and their add-ons. Payers reimburse the parent codes at a higher rate due to the work required to set up the patient and establish the site and start the IV (including administering local anesthesia when used). The higher payment also covers the supplies needed for the infusion, including the subcutaneous catheter or port, standard tubing, and syringes. You should count all of this as bundled into the initial service, and you can only report one initial service per site.

Choose codes for add-on services based on their purpose:

• Additional: The continued infusion of the same drug following a primary or initial service
• Sequential: The infusion of a new drug at the same site of the initial service
• Concurrent The infusion of a new drug at the same time as another drug

Test yourself: A patient undergoes two hours of IV chemotherapy. During the infusion, the provider administers a second, therapeutic drug for one hour.

In this situation, your coding should be:

• 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the initial IV set up and first hour of the chemotherapy infusion;
• +96415 (… each additional hour (List separately in addition to code for primary procedure)) for the additional, second hour of the chemotherapy infusion; and
• +96368 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)), for the concurrent infusion of the therapeutic drug.

Tip 4: Organize Your Information

Last, Loya offered a tried-and-true method for organizing complex infusion information into a manageable visual format. She suggested creating a grid where you can place information regarding the medication, category type (hydration, therapeutic, or chemotherapy), administration route (infusion, IV push, or injection), and the start/stop times. Once organized in the grid, Loya noted, the information can be easily arranged into the associated CPT^® or HCPCS Level II codes, along with the number of units for each code.

Remember: “Start by identifying your initial service before coding the remaining services. You can only select one initial code for any one IV site or for the same encounter. Then identify other services and assign the codes as ‘add on’ services to the initial service for any remaining administration,” Loya emphasized.