Oncology & Hematology Coding Alert

Question: Our physician treated a patient of non-Hodgkin’s lymphoma with rituximab. There is documentation for an adverse reaction within the first 15 minutes of the infusion. How can we report this drug administration? Can we submit a code for infusion or do we report this as a push?

New York Subscriber

Answer: Your physician intended to administer rituximab as an infusion, perhaps lasting up to an hour. The most appropriate code for the infusion is 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). Your physician does not elect to discontinue the infusion but is forced to stop the infusion in the event of an adverse reaction. 

The best approach to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, in this case, code 96413.

According to CPT®, you should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient.” Modifier 53 describes an unanticipated problem which is beyond the physician’s or patient’s control and which eventually necessitates discontinuation of the procedure. 

Do not report as push: CPT® guidelines include “an infusion of 15 minutes or less” as one definition of a push but you will not be correct to report rituximab administration as a push. You should hence not submit a push code, say for example, 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug). The code 96413-53 describes the ordered and provided service more accurately than a push code in this case. Palmetto GBA also answered a similar question.  The dialogue can be found here: http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EEM778180?open

Also submit HCPCS code: Keep complete documentation to describe the circumstances of discontinuation, the administration start and stop times, and the amount of drug delivered and discarded. For the drug, you submit the HCPCS code J9310 (Injection, rituximab, 100 mg). In this case, you should be able to report the entire amount, assuming that your physician discarded the amount not administered.

Report the diagnosis: Remember also to report the appropriate ICD- 9-CM diagnosis codes. You may consider one or more of the following codes:

• V58.12, Encounter for immunotherapy for neoplastic condition
  
• 202.8x, Other malignant lymphomas
  
• V64.1, Surgical or other procedure not carried out because of contraindication
  
• E933.1, Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use.
  

Also: Check if your physician performed any E/M services while attending to the patient.