Oncology & Hematology Coding Alert

Question: Our physician ordered an hour-long infusion of Rituximab for a patient with non-Hodgkin’s lymphoma. About 15 minutes into the infusion, the patient had an adverse reaction to the drug, and the provider stopped the procedure. How should I code this? Can I report a push, as the patient received the drug for 15 minutes? Or do I document the infusion with 96413 and append a modifier to show the procedure was not completed as planned? And, if so, do I use modifier 52 or 53?

Massachusetts Subscriber

Answer: Even though CPT^® guidelines define a push as “an infusion of 15 minutes or less,” it would be incorrect to document this scenario with a push code such as 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug). That’s because the service as ordered was a one-hour infusion, and not a push, and even though the service was not completed as planned, you must document the service that was originally intended.

The correct way to report what happened is to use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug), as that was the service your oncologist originally planned. Then you would append modifier 53 (Discontinued procedure), not 52 (Reduced services).

Why? In Appendix A, CPT^® guidelines state that modifier 52 should be used when “a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional.” Guidelines for modifier 53, however, state the modifier should be used when the “physician or other qualified health care professional … elect[s] to terminate a surgical or diagnostic procedure … due to extenuating circumstances or those that threaten the well being of the patient.” In other words, use of modifier 52 suggests the physician alone has elected to cancel the procedure, whereas 53 suggests the patient’s condition has forced the physician to terminate the service.

And remember: If you’re coding for the drug (J9312, Injection, rituximab, 10 mg), you should be able to report the entire amount, assuming you discarded the amount not administered. Your documentation should describe the circumstances, the administration, start and stop times, and the amount of drug delivered and discarded. The amount of drug discarded should be reported on a separate line with modifier JW (Drug amount discarded/not administered to any patient).

Also, you’ll need to use the following ICD-10-CM codes to fully describe the circumstances of the encounter:

• Z51.12 (Encounter for antineoplastic immunotherapy)
• C85.8- or C85.9- (Other specified and unspecified types of non-Hodgkin lymphoma)
• Z53.09 (Procedure and treatment not carried out because of other contraindication)
• T45.1X5A (Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter)