Oncology & Hematology Coding Alert

Question: We performed a chemotherapy infusion on a patient lasting 115 minutes. Prior to the infusion, we performed a 30-minute antibiotic infusion. What is the correct way to code this?

California Subscriber

Answer: The key to coding this scenario lies, first, in sequencing the administration codes correctly and, second, choosing the correct prophylactic administration code.

For the chemotherapy, you’ll use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour. This will be the first-listed procedure code, even though it was not the first procedure performed. If the setting is a facility, “the initial infusion is based on using the hierarchy,” requiring chemotherapy to be listed first, per CPT^® guidelines. If the service is performed in an office setting, and assuming the chemotherapy is the primary reason for the patient encounter, CPT^® guidelines instead state that “an initial infusion is the key or primary reason for the encounter reported irrespective of the temporal order in which the infusion(s) or injection(s) are administered.”

You will also be able to use add-on code +96415 (... each additional hour [List separately in addition to code for primary procedure]) to report the remaining 55 minutes of the infusion time since it is over the midway point of the time indicated in the descriptor or more than 31 minutes into the second hour.

As 96413 is the primary code, you would then report the antibiotic infusion with an add-on code for the prophylactic infusion: +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion of a new drug/ substance, up to 1 hour [List separately in addition to code for primary procedure]). This is the appropriate code for the 30-minute antibiotic infusion, as the time is greater than 15 minutes and the code describes the therapeutic infusion you refer to in your question.

Why? Even though CPT^® guidelines tell you that “the administration of medications (eg, antibiotics, steroidal agents, antiemetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported using 96360, +96361, 96365, 96379 as appropriate,” and even though +96367 is not on that list, the correct code for the antibiotic infusion in this case is +96367. The guidelines only allow one initial service per encounter, which is coded with the 96413 in this example. As you do not provide any information that the protocol or patient requires separate IV sites, the antibiotic infusion in this situation would be regarded as subsequent.

Putting it all together: For this encounter, your claim for the chemotherapy and therapeutic drug administration will look something like this:

• 96413 for the first hour of chemotherapy
• +96415 for the remaining 55 minutes of chemotherapy
• +96367 for the 30-minute antibiotic infusion

Your claim should also specify the substances or drugs used and billed as a reimbursable expense for both the chemotherapy and the antibiotic infusion as long as the medications represented a cost to your office. If any of the medications did not reflect a cost, they may be reported on the claim to show the substances used for the administration charge. The medications would not include dollar amounts, so they would not be reimbursed.