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Oncology & Hematology Coding Alert

Reader Question:

Inpatient Chemotherapy

Published on Fri Dec 21, 2012

Question: When is it appropriate for a physician to bill for inpatient chemotherapy, 96408-96412?

South Carolina Subscriber

Answer: There are no circumstances in an inpatient environment that would allow the physician to bill chemotherapy, 96408-96412. According to Medicare, these codes are for administering chemotherapy drugs in an outpatient setting only and physicians cannot use them because they imply that hospital staff administer the agents, the service takes place in a hospital room, and the facility provides the equipment and supplies. All of these represent an expense to the hospital and not the physician's office.
 
While there is a distinction between hospital inpatient and hospital outpatient treatment, physicians generally cannot bill for chemotherapy administration in either setting. Although the patient was not admitted or assigned a hospital bed, outpatient chemotherapy treatment takes place inside the hospital. When hospital outpatient chemotherapy is provided, hospital staff also complete the preparation and administration. So, the coding implications are similar to inpatient services. Rather than the outpatient service representing an expense to the physician, it represents an expense to the hospital, which supplies the room, equipment and nursing staff.
 
The physician's only service is writing an order for hospital staff to follow. However, there might be an occasion when the physician administers the chemotherapy, for example, intraventricularly through an Ommaya reservoir. In this case you would code 96542 (chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents).
 
The physician cannot bill for the chemotherapy procedure, but can bill for evaluation and management services he or she physically performs in the outpatient department.  In this case, the physician bills for E/M services, 99221-99223 (initial hospital care) or 99231-99233 (subsequent hospital care).
 
-- Answers to "Reader Questions" and "You Be the Coder" provided by Cindy Parman, CPC, CPC-H principal and co-founder of Coding Strategies Inc., in Dallas, Ga.; Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.; and Margie Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant based in New Orleans.

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