Oncology & Hematology Coding Alert

Question: We are unable to get paid by our Medicare carrier for chemotherapy administration (96410-96412) when we also charge non-chemotherapy administration (90780-90781). We use modifier -59 with the non-chemotherapy codes when done on the same day. What can we do?

Florida Subscriber

Answer: According to most local medical review policies, the following Medicare guidelines apply:

1) Both the infusion codes 90780-90781 (therapeutic or diagnostic infusions) and the chemotherapy administration codes 96410 (infusion technique, up to one hour); 96412 (infusion technique, one to eight hours, each additional hour); and 96414 (... initiation of prolonged infusion requiring the use of a portable or implantable pump) are considered payable when modifier -59 (distinct procedural service) is appended.

2) There is no payment for hydration therapy, which is also coded with 90780-90781, with chemotherapy administration regardless of modifier application.

3) Injections (90782-90788) are not paid with administration, although separate payment may be allowed for the cost of the drug.

The Medicare carrier may be denying the service based on the lack of a HCPCS code for the infused drug. For example, if a practice includes 90780 for an injection of granisetron, it should also include J1626 to describe the drug. You may also need to submit additional information regarding the medical necessity of non-chemotherapy infusion, including the patients medical condition, and physician orders.

Always make certain that when modifier -59 is appended to the service that is normally bundled into the primary procedure, the criteria for a distinct and separate service are documented. The service may represent a different session, patient encounter, procedure or surgery. Overuse of modifier -59 may be an indicator to payers that a sample chart review is necessary to ensure that the separate nature of the services provided is adequately documented.


Questions answered by Lillie McCallister, CPC, president of Double Diamond Enterprises, a coding and billing consulting firm in Conroe, Texas; Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga.; Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans; Imelda Y. Lee, RHIA, CTR, coding supervisor for the UPG/UT Health Science Center in San Antonio; and Cathy Klein, LPN, CPC, senior consultant with Health Care Economics Inc. in Indianapolis.