Oncology & Hematology Coding Alert

Hint: Make sure the medical record backs up how much time you report.

Infusion coding can sometimes become intricate based on several factors, so make sure you know how to handle certain situations by checking out the following infusion FAQ.

1. Record Reason for Lengthy Infusion Time

Question:  Our oncologist ordered a 90-minute chemotherapy infusion service, but the infusion lasted a few minutes longer than that. Is it OK to report the entire infusion time?

Answer: You may report the codes for the entire infusion time but be sure the medical record notes why the infusion took longer than the prescribed time. You want to be able to prove medical necessity to an auditor because it is not appropriate to extend an infusion time just to increase reimbursement.

For example:  If the patient has a chemotherapy infusion for one hour and 33 minutes, you would report 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 33 minutes beyond the first hour.

As your question suggests, if the patient receives a 90-minute infusion, you would report only an initial hour code (96413). A parenthetical note following +96415 indicates it is "for infusion intervals of greater than 30 minutes beyond 1-hour increments." 90 minutes is only 30 minutes beyond one hour. It is not "greater than 30 minutes" beyond the hour.

Bottom line: While some infusions will last longer than the prescribed 90 minutes, slowing the infusion rate to ensure billing for an additional code would not be appropriate. Likewise, infusion time may fall short of the 90-minute order as well. Be sure to document the services provided and start/stop times so coding is accurately reflective of the effort and resources expended. A notation on the time variance is recommended to support the care.

2. Choose Initial Infusion Type

Question: A patient presents for chemotherapy treatment. The oncologist performs a 30-minute antibiotic infusion, then a 115-minute chemotherapy infusion. Which infusion does the insurer consider initial in this scenario?

Answer: For coding purposes, payers consider the initial infusion the "main reason" the patient is seeing the oncologist. When you're coding for multiple substances, administration order takes a back seat to the infusions importance.

In your case, the chemotherapy is the main reason the patient is having infusion therapy. Thus, you should code the chemotherapy infusion first.

On the claim, report the following:

• 96413 for the first hour of chemotherapy
• +96415 for the remaining 55 minutes of chemotherapy
• +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 antibiotic infusion.

Note: Do not report +96415 (an additional hour of chemotherapy infusion) for less than 31 minutes of service beyond the first hour. So, if the notes indicate that a patient »»» had 75 minutes of chemotherapy, you'd only report 96413. Also, you should not report +96367 if the total infusion time is less than 16 minutes. When infusion time is 15 minutes or less, the service would be coded as an IV Push (IVP).

3. Keep Hydration Coding on Course

Question: The oncologist often orders a 35-minute intravenous infusion of Phenergan with a 250-cc bag of common saline solution for patients with diarrhea and vomiting. Should I report hydration and therapeutic drug administration?

Answer: Stick to drug infusion code 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) in this situation. You should not report the hydration separately.

Here's why: CPT^® states that fluid used to administer the infusion of a drug is -incidental hydration- that you cannot report separately. And in the situation described, the provider administers the drug through the same IV. If you report both hydration and 96365, payers would ask you for a refund when following CPT^® guidance to support the reporting of services.

4. Count Minutes Carefully for Chemo Infusion

Question: What's my coding for a patient with primary neoplasm of the rectosigmoid junction and secondary neoplasm of the liver who receives palliative chemotherapy of 350 mg/m2 irinotecan intravenously in 500 mL D5W (5 percent dextrose in water) over 90 minutes?

Answer: For 90 minutes of chemotherapy infusion, you should report 96413.

Don't overcode: You should not report +96415 in addition to 96413. A 90-minute administration means that you have one hour plus 30 minutes, which falls short of the +96415 requirement by one minute. You'd need an additional 31 minutes beyond the initial hour to report this "additional hour" code, according to CPT^® guidelines.

Why accuracy matters:  Remind your clinical and medical providers to record the actual start and stop times accurately for all injections and infusions. Rounding down an infusion from 31 minutes to 30 shortchanges your practice.

If you code for the drugs you use, you may also report J9206 (Injection, Irinotecan, 20 mg). Remember to factor in the 20 mg included in the descriptor when you choose your units.

Coding the drug: The oncologist uses nine single-dose-vials (SDV) containing 40-mg in each vial (since he administers 350 mg irinotecan, 10 mg is left in the last SDV vial). The oncologist documents the administration of 350mg and documents the wasted amount of the remaining 10 mg).

Since the HCPCS code (J9206) to report the medication is defined as 20 mg, 350mg/20mg = 17.5 units of irinotecan. For Medicare, you should round the dose up to the nearest whole number, or 18 units. Check your payor policy to determine if they also round to the nearest whole unit. If not, you may need to report a fraction of the code and the wasted fraction with a modifier JW (Drug amount discarded/not administered to any patient).

This is important: Payers have varying policies on coding for drug waste. Check the specific payer to determine its preference, such as recording wasted drugs on a separate line or by appending modifier JW (Drug amount discarded/not administered to any patient).

You should assign the primary diagnosis of Z51.11 (Encounter for antineoplastic chemotherapy).

Next, report the primary neoplasm of rectosigmoid junction with C19 (Malignant neoplasm of rectosigmoid junction) and the secondary neoplasm of liver using C78.7 (Secondary malignant neoplasm of liver and intrahepatic bile duct).

Finally, you can also add Z51.5 (Encounter for palliative care) as the fourth listed diagnosis code.

Caution: If you omit chemotherapy encounter code Z51.11 and report palliative care code Z51.5, some payers won't cover the chemotherapeutic drug. You should assign Z51.11 as the principal/primary diagnosis to indicate the patient presented for chemotherapy services.

5. Earn Reimbursement for Incomplete Infusions

Question: About 30 minutes after starting paclitaxel (Taxol®) administration for a patient, the nurse noticed the pump had leaked onto the floor. It was unclear how much Taxol was wasted and how much the patient actually received. Can the administration be billed?

Answer: You can bill the administration. The challenge here lies in assigning the code for a push or infusion. By definition, a push technique implies an infusion of 15 minutes or less. The correct code for a push technique is 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug). For administration of drugs that lasts more than 15 minutes and up to 1 hour, you report an infusion. You choose code 96413 for an infusion.

In the specific situation described, the patient is clearly given an infusion. So, the best code is 96413. However, the infusion is not completed as the pump leaked. If the infusion was discontinued at the time the pump error was found, you may append modifier 53 (Discontinued procedure) to code 96413 to account for the discontinuation in the infusion. If the infusion continued after the malfunction was identified and resolved, then the total time the infusion ran would be reported. Look for any additional services provided as described by the care detail including any documented physician intervention.

Tip: If you are coding for the drug paclitaxel (Taxol®) with code J9267 (Injection, paclitaxel, 1 mg), you should report the entire amount prepared for administration.