Oncology & Hematology Coding Alert

Answer: Herceptin is unlike traditional chemo-therapy drugs. It is a biological response modifier. Herceptin, also know as Trastuzumab (J9355), is a monoclonal antibody and an antineoplastic agent. It should be billed using 96410 (chemotherapy administration, intravenous; infusion technique, up to one hour). The administration of other drugs such as growth factors, saline and diuretics to patients with cancer, or the administration of antineoplastics to patients with a diagnosis other than cancer, is reported with codes 90780 through 90784 (therapeutic or diagnostic infusions[excludes chemotherapy]).

Almost all chemotherapy administration services are billed under 96400-96549. In Section 15400A of the Medicare Carriers Manual, it states that 96400 through 96450, 96542, 96545, and 96549, are to be used when reporting chemotherapy administration when the drug is an antineoplastic and the diagnosis is cancer. All forms of administration (push, infusion, pump, intramuscular, subcutaneous) are covered by these codes.

Private insurers may allow use of these codes for another class such as hematopoietic growth factor drugs. Infusions of other types of drugs (such as antiemetics, antibiotics, steroids, analgesics, narcotics, and hematopoietic growth factors) and of saline solution are billed using 90780 (IV infusion for therapy/diagnosis, administered by physician or under supervision of physician; up to one hour) and 90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) except in cases in which private insurers allow some of the drugs to be billed under the administration codes.

Because Herceptin is an antineoplastic drug and J9355 is included in the Chemotherapy Drugs section of HCPCS, you would presumably use the chemotherapy administration codes 96410 and 96412 (chemotherapy administration, intravenous; infusion technique, one to eight hours, each additional hour). Many carriers have a policy that specifically addresses Herceptin.

This question was answered by Laurie Lamar, RHIA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology. (Her response does not reflect the opinion or position of ASCO.)