Part B Insider (Multispecialty) Coding Alert

Know the CCI edits when attempting to report chemotherapy administration along with portable pump refills.

Question: Are we able to bill 96521 and 96416 on the same date? We had one payer who reimbursed both, but Medicare has been denying our claims. Do we need to use a modifier?

Answer: You should not report 96416 (Chemotherapy  administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump) on the same date as 96521 (Refilling and maintenance of portable pump).

Why: Any payers that adopt Medicare's Correct Coding Initiative (CCI) edits prohibit reporting 96521 with 96416. 96416: You should report pump initiation (96416) when the provider initiates prolonged infusion with a portable or disposable pump in the office.

To meet code requirements, the infusion (whether continuous or intermittent) must last a minimum of eight hours. Because the patient leaves the office for the duration of the infusion, you may not know the precise completion time, but you should record the disconnect time when the patient returns to the office. A treatment plan indicating pump run time and a record of the drug details is also a good idea. 96521: In contrast, 96521 is appropriate when portable pumps require periodic refilling and maintenance.

Do not report the initial infusion code (96416) for subsequent infusions using the same pump. And do not use refill code 96521 for initiation.

Exception: When a patient's pump has been completely disconnected -- such as in an intermittent regimen where the patient is instructed to discontinue the pump at home when administration is complete -- and later the patient presents for another infusion, you may use 96416. That's because this is a true initiation rather than a continuation of a previous service.