Oncology & Hematology Coding Alert

Question: A patient with primary neoplasm of the rectosigmoid junction and secondary neoplasm of the liver receives palliative chemotherapy of 350 mg/m2 irinotecan intravenously in 500 mL D5W (5 percent dextrose in water) over 90 minutes. How should I code this?

South Dakota Subscriber

Answer: For 90 minutes of chemotherapy infusion, you should report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

DO NOT report +96415 (... each additional hour [List separately in addition to code for primary procedure]) in addition to 96413. A 90-minute administration means that you have one hour plus 30 minutes, which falls short of the +96415 requirement by one minute. You’d need an additional 31 minutes beyond the initial hour to report this “additional hour” code, according to CPT^® guidelines.

Why accuracy matters: Remind your clinical and medical providers to record the actual start and stop times accurately for all injections and infusions. Rounding down an infusion with an actual time of 31 minutes to 30 minutes would shortchange your practice. That is why the providers and nurses should document the actual time, and it is so important! Imagine similarly if the situations had an actual time of 30 minutes, like in the question, and if it was rounded up to meet the code time requirements, that would also be incorrect.

If you are billing for the drugs you use, you may also report J9206 (Injection, Irinotecan, 20 mg). Remember to factor in the 20 mg included in the descriptor when you choose your units based on the total calculated dosage given and supported in the medical record/medication administration log for the infusion administration.

This is important: Irinotecan is packaged in a single-dose-vial. Therefore, if there is an additional amount of drug that must be wasted after preparing/administering the patient’s dosage, then the wastage amount can also be billed as long as there is supporting documentation. Payers have varying policies on coding for drug waste. Check the specific payer to determine its preference, such as recording wasted drugs on a separate line or by appending modifier JW (Drug amount discarded/not administered to any patient).

You should assign the primary diagnosis of Z51.11 (Encounter for antineoplastic chemotherapy).

Next, report the primary neoplasm of rectosigmoid junction with C19 (Malignant neoplasm of rectosigmoid junction) and the secondary neoplasm of liver using C78.7 (Secondary malignant neoplasm of liver and intrahepatic bile duct).

Finally, you can also add Z51.5 (Encounter for palliative care) as the fourth listed diagnosis code.

Caution: If you omit chemotherapy encounter code Z51.11 and report palliative care code Z51.5, some payers won’t cover the chemotherapeutic drug. You should assign Z51.11 as the principal/primary diagnosis to indicate the patient presented for chemotherapy services.