Oncology & Hematology Coding Alert

Keep a watch on time of infusion and earn for sequential drugs, if any.

When coding for chemotherapeutic injections and infusions, you’ll need to be able to unravel the complexities of administering chemotherapy, complex drug, or biologic agent for treatment to accurately report your provider’s services, which are considered complex due to the higher likelihood of adverse events. (See Oncology Coding Alert, Vol. 17, No. 1 to learn about coding for injections and infusions of non-chemotherapeutic substances.) 

Route and time are key: Like the codes for injections and infusions of regular non-chemotherapy and simple medications, the codes for chemotherapy and complex drug administration are determined based on the route and time of the drug administration. 

Exception: Some codes for chemotherapy and complex drug administration are based on the type of medication. Example: Code 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) is specific to administration to the administration of non-hormonal anti-neoplastic drugs.

Count Lesions for Intralesional Chemotherapy

When reporting chemotherapy, where your physician directly administers the drug in to the cancerous lesion, you check how many lesions were documented as having been treated. Seven lesions is the key number. You report code 96405 (Chemotherapy administration; intralesional, up to and including 7 lesions) when your physician administers the chemotherapy in to the cancerous lesion in up to and including 7 lesions. When your physician treats more than 7 lesions, you submit code 96406 (Chemotherapy administration; intralesional, more than 7 lesions).

Check Any Additional Drugs for Intravenous Push and Infusions

When your physician administers the chemotherapy by intravenous push, you select codes based on whether the administration was a single, or initial push, or an additional chemotherapeutic substance. Accordingly, you submit codes 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug) if the medication was the initial or only substance.  And you would report +96411 (Chemotherapy administration; intravenous, push technique, each additional substance/drug [List separately in addition to code for primary procedure]) if the medication was the second or more in the series of multiple chemotherapeutic substances given during the encounter.

Similarly, when your physician administers the chemotherapy by intravenous infusion, you check for initial or additional substance. You also will confirm the timing of the infusion. For the infusion of a single substance that lasts up to an hour, you submit code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). Subsequently, for every additional hour of infusion of the same substance, you report the add-on code +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]).

Watch out for prolonged infusions: You will typically report prolonged infusions as the ones that last more than 8 hours. For a prolonged infusion, you report code 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump).

Check the procedure notes to confirm the use of an infusion pump: Your physician may use a pump to administer the chemotherapy. This pump may be attached to a central line which enables your physician to administer the drug slowly into the blood stream over a period of few days or weeks. This service is known as continuous intravenous infusion (CIV). When your physician mentions CIV in the clinical note, you confirm that your physician used a pump for the prolonged administration of the chemotherapy. 

Confirm any sequential infusions: Your physician may administer 2 or more chemotherapeutic or complex drugs in a sequence, i.e. a different drug after an initial one. In such a case, irrespective of the timing of the initial infusion, you submit code +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]).

Tip: You can use code 96415 and 96417 with code 96413.

Make note of timing: When you report the add-on codes +96415 and +96417, you count every additional substance given (96417) or each additional hour of infusion exceeding 30-minutes beyond the one hour increment (96415) each unit of the code. 

Be Specific for Intra-Arterial Route

Your physician may go the arterial route to administer some drugs. In this case, you have discrete codes to choose from. As for the intravenous route, you determine the duration of infusion. If your physician administers the chemotherapy by an intra-arterial push, you submit code 96420 (Chemotherapy administration, intra-arterial; push technique). 

For intra-arterial infusions of up to an hour, you submit code 96422 (Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour). For every additional hour of infusion, you submit +96423 (Chemotherapy administration, intra-arterial; infusion technique, each additional hour [List separately in addition to code for primary procedure]). “And like the intravenous infusions, each unit of this code is for each additional hour of infusion exceeding 30-minutes beyond the one hour increment,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. Like for intravenous infusions, you have a specific code for prolonged intra-arterial infusion, i.e. 96425 (Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion [more than 8 hours], requiring the use of a portable or implantable pump).

Turn To 96523 for Port Flush

If the only service provided at the encounter is to flush the access catheter or port with saline, make sure you don’t forfeit pay for this service. You submit code 96523 (Irrigation of implanted venous access device for drug delivery systems) for irrigation of venous access. “However, if other services are reported on this date, follow the CPT® instructional note, do not report with any other services on the same date of service,” Loya says.

Learn With This Example

Follow this scenario to gain clarity coding chemotherapy administration. You may read that your physician administered rituximab over 173 minutes (11:27 AM to 02:20 PM), cyclophosphamide over 64 minutes (01:50 PM to 02:54 PM), and doxorubicin over 23 minutes (02:55 PM to 03:18 PM) through intravenous infusion. Additionally, vincristine was given as an intravenous push over a minute. 

What to report: In this case, the total duration for rituximab administration is 2 hours and 53 minutes. For the initial hour of this administration, you report code 96413. For the additional 1 hour and 53 minutes, you submit two units of code 96415. For cyclophosphamide infused over 64 minutes, the administration of this different chemo substance is reported with 96417. The doxorubicin was infused over 23 minutes.  You submit another unit of 96417. Lastly, for the IV push for vincristin, you submit code 96411.

3 Key Factor to Remember: 

1. The codes for chemotherapy are inclusive of the services of administering the drug and preparation of the drug.

2. When your physician uses saline to administer chemotherapy, the hydration is incidental and you do not separately report the administration of saline.

3. You do not report these codes for a physician if these services are provided in a facility (non-office) setting.