Oncology & Hematology Coding Alert

If you fall prey to a common subsequent infusion trap, you could face requests for multiple $40 refunds. Keep your hard-earned dollars with this look at reporting additional hours of subsequent chemotherapy infusions.

Scenario: You've coded a patient's initial chemotherapy infusion. Now you need to code a subsequent chemotherapy infusion that lasted longer than 90 minutes. You determine that for the subsequent infusion's first hour, you should report +96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion [different substance/drug], up to 1 hour [List separately in addition to code for primary procedure]).

Now you have to decide how to report the additional time beyond that hour. Should you report +96417 again or report +96415 (... each additional hour [List separately in addition to code for primary procedure])?

Solution: The correct choice is +96415, says Tracy Helget, CPC, with Medical Associates of Manhattan PA in Manhattan, Kan.

CPT instructs you to report +96415 "for infusion intervals of greater than 30 minutes beyond 1-hour increments."

Good news: Medicare's national rate for +96417 is roughly $40 more than for +96415, so by making the proper choice, you prevent auditors from asking for refunds and wondering what other reimbursement you owe them.

Now that you have the rule down pat, determine which CPT codes you should report for the following example:

Cisplatin 11:27 to 13:00

Gemzar 13:15 to 15:55.

What to do: Both cisplatin and Gemzar are antineoplastics, meaning they share the same drug classification, says Helget.

You should report both using chemotherapy administration codes.

You may report only one "initial" service unless protocol requires two separate IV sites, said Brenda Chidester Palmer, CPC-I, CPS-P, in her Coding Institute presentation, "Infusion Coding: Fill-Up On These Expert Guidelines and Get Paid What You Deserve" (available online at www.codingconferences.com/oncology08cds_doc_books.htm).

For our example, assume you have a single IV site and the cisplatin admin is the "initial" infusion (96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

Remember that you should report the drug that is the primary treatment for the patient's condition as the initial infusion, Helget says. Treatment plans differ because the oncologist tailors them to the individual patient.

The cisplatin infusion lasts one hour, 33 minutes.

Hour 1: To report the first hour of the cisplatin infusion, you should apply 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug), Helget says.

+ 33 minutes: Report +96415 (... each additional hour ...) for the additional 33 minutes after the first hour, says Helget.

The Gemzar infusion lasts two hours, 40 minutes.

Hour 1: You should report +96417 (... each additional sequential infusion [different substance/drug], up to 1 hour ...) for the first hour of the Gemzar infusion. Remember that you should report +96417 only once per sequential infusion of a different substance and then turn to +96415 for additional hours, Chidester Palmer says.

+ Hour 2: Report +96415 for the second hour of infusion.

+ 40 minutes: For the final 40 minutes, report +96415 again, Helget says.

Crucial: Be sure you calculate the infusion time separately for each drug, Helget says.

In other words, you shouldn't add the cisplatin's 33 additional minutes to the Gemzar's additional 1 hour, 40 minutes when you decide your +96415 coding.

And be sure you're using the actual infusion times -- based on start and stop times -- when you perform your calculations, Chidester Palmer says.

Summary: For the example scenario, you should report the following administration codes, concludes Helget:

• 96413 x 1 (cisplatin)

• +96417 x 1 (Gemzar)

• +96415 x 3 (cisplatin x 1, Gemzar x 2).

By knowing the rules, you've saved your practice the hassle and expense of +96417 paybacks -- and reported +96415 the appropriate number of times for each separate drug administered.