Oncology & Hematology Coding Alert

Liver cancer cases are on the rise, so you need to be equipped to code the intra-arterial (IA) infusions doctors may order as treatment. Even if you-ve honed your IV infusion coding skills to be razor sharp, you can't afford to miss these expert IA coding tips, revealing where IA and IV coding rules are the same -- and where they differ.

The codes: CPT 2007 lists four codes under "Intra-Arterial Chemotherapy":

- 96420 -- Chemotherapy administration, intra-arterial; push technique

- 96422 -- - infusion technique, up to one hour

- +96423 -- - infusion technique, each additional hour

- 96425 -- - infusion technique, initiation of prolonged infusion (more than 8

hours), requiring the use of a portable implantable pump.

Payers are most likely to cover IA chemo, which is not as common as IV chemo, for liver cancer and colon cancer metastatic to the liver.

You should report primary liver cancer with 155.0 (Malignant neoplasm of liver and intrahepatic bile ducts; liver, primary), says Linda Templeton, CPC, CPC-H, CCS-P, an independent coding consultant based in Rossford, Ohio.

The most common type of primary liver cancer is hepatocellular carcinoma, Templeton notes. Other types include cholangiocarcinoma, hepatoblastoma and angiosarcoma, she says.

ICD-9 classifies colon cancer metastatic to the liver under 197.7 (Secondary malignant neoplasm of respiratory and digestive systems; liver, specified as secondary), Templeton says.

According to official ICD-9 guidelines, "When a patient is admitted because of a primary neoplasm with metastasis, and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present," Templeton says.

Translation: Report secondary neoplasm code 197.7 when a patient with colon cancer metastatic to the liver presents for secondary liver neoplasm treatment only.

Term: CPT guidelines indicate that the same definition of "push" applies to both IV and IA administration, Templeton points out:

a) "an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient"

OR

b) "an infusion of 15 minutes or less."

When your provider documents an IA chemotherapy push, you should report 96420.

Example A: A nurse administers a 25-minute IA chemotherapy injection. She is present the entire time and observes the patient throughout the injection time. You should report 96420.

Example B: A nurse administers a five-minute IA chemotherapy infusion. You should report 96420.

When the patient receives an IA chemotherapy infusion lasting more than 15 minutes, you should report 96422 for the first hour, according to the code's descriptor.

Example: The nurse administers a 45-minute IA chemotherapy infusion. You should report 96422.

Don't miss: You should use add-on code 96423 to report each additional infusion intervals more than 30 minutes beyond a one-hour increment.

That means that if the total IA infusion time is one hour and 30 minutes, you should report only 96422. You should not report 96423 along with 96422 because the total time is only 30 minutes -- not "more than 30 minutes" -- beyond a one-hour increment.

Test yourself: Suppose a nurse administers a five hour, 17 minute IA chemotherapy infusion. Determine which CPT codes and how many units you should report.

Solution: Report one unit of 96422 for the first hour. Report four units of 96423 for hours two through five. You should not report the remaining 17 minutes separately because they do not meet the "more than 30 minutes" requirement for reporting an additional 96423 unit.

Helpful: These timing rules for IA infusion codes 96422 and 96423 are the same as those for the IV infusion codes you use more commonly, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and +96415 (- each additional hour).

Code 96425 describes prolonged infusions longer than eight hours that require portable or implantable pump use.

You may report this code regardless of whether you own or bill for pump rental because this code covers infusion initiation rather than the physical pump.

When the providers offer refilling or maintenance of an IA portable pump or implantable infusion pump or reservoir , you should choose the appropriate code from 96521-96523, the same codes you would use if the patient received IV pump delivery.

Correctly identifying whether you should report an "initial" or "sequential" code is one of the more complicated aspects of reporting IV services such as hydration, chemo and non-chemo therapeutic infusions.

Why: The order in which the provider administers IV infusions or injections during a patient encounter does not dictate which service you report as initial, says Sarah L. Goodman, MBA, CPC-H, CCP, president and CEO of SLG Inc. in Raleigh, N.C.

"The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur," says Chapter 12, 30.5E, of the Medicare Claims Processing Manual.

Example: A patient presents for IV chemotherapy treatment -- the key reason for the encounter. The provider performs a therapeutic, non-chemotherapy IV infusion or injection (such as, antibiotics, steroidal agent, antiemetics, narcotics, etc.) first. You should report initial IV chemo code 96413 and sequential IV infusion code +90767 (Intravenous infusion, for therapy, prophylaxis or diagnosis [specify substance or drug]; additional sequential infusion, up to 1 hour).

Watch out: You won't find "initial" or "sequential" IA chemotherapy codes in CPT.

That means that unless your payer instructs you otherwise in writing, you may report an IA infusion with 96422 and an initial IV code, such as 90765 (Intravenous infusion, for therapy, prophylaxis or diagnosis [specify substance or drug]; initial, up to 1 hour) on the same day for the same patient.