Oncology & Hematology Coding Alert

Question: We send pumps home with some of our patients and need to know how to bill for the infusion. Can we bill 96410 and 96412 for the first eight hours and then 96414 for the remainder?

New York Subscriber
Answer: If your oncologist initiates a chemotherapy infusion in the office and then sends that patient home with the pump, you can report 96414 (... intravenous; infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump). But carriers will not pay you separately for the disconnection from the pump, which they consider included in 96414.

You should report 96414 and 96425 (... intra-arterial; infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump) for a prolonged infusion (at least eight hours) of antineoplastic medication. Make sure that 96414 and 96425 require a pump or your physician administrators the drug at a controlled rate to avoid toxicity. Also, you cannot use another means of administration.

Carriers may reimburse you on a daily or monthly basis for an ambulatory infusion pump (E0781) from either a durable medical equipment vendor or physician's office. Insurers will reimburse for refilling and maintenance of a portable pump (96520) or an implantable pump or reservoir (96530) once per episode of care. Suppose your physician provided a separate E/M service, such as an established patient visit (99211-99215), on the same day as the refilling and maintenance of a pump. You could attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

But you should not expect payment for 96520 (Refilling and maintenance of portable pump) and 96530 (Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic [e.g., intravenous, intra-arterial]) in addition to chemotherapy administration on the same date of service. Carriers will reimburse the code with the highest allowance. And chemotherapy services include the maintenance and flushing of an external catheter, such as a Hickman or Broviac.

Code 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) is mutually exclusive to 96414, but CMS and other carriers allow you to use a modifier, such as -59 (Distinct procedural service), to differentiate between the services provided.

For chemotherapy administration codes 96400-96410, 96414-96422 and 96425-96530, you can report only one unit of service per code per day, regardless of the number of agents. Report 96414 or 96425 on the first day of each chemotherapy infusion cycle initiated in a physician's office. You could separately bill the additional therapy on the same day if your oncologist uses the intravenous push technique (96408, 96420). You cannot separately bill an infusion (96410-96412 [...]