Pediatric Coding Alert

Real-world case study teaches you to apply CPT 2006 guidelines

If you provide outpatient pediatric chemotherapy, there's no time like the present to make sure your coding is up to speed.

CPT 2006 introduces 11 new chemotherapy administration codes, revises three codes and deletes eight codes. "Every now and then it is necessary to completely revise a section of the CPT Manual , primarily because technology has advanced, procedures have changed and/or there are new definitions for services reported with existing procedure codes," writes Cindy C. Parman, CPC, CPC-H, RCC, cofounder of Georgia-based Coding Strategies Inc. in the December 2005 Coding Edge article "Give Me a Hifi!" The updated section offers numerous guidelines on reporting these procedure codes.

Learn how to apply the rules with the following real-world case study:

Scenario: A patient who is scheduled for chemotherapy receives 45 minutes of hydration before beginning chemotherapy. The child then receives an antiemetic infusion for 40 minutes. After this, the patient receives one chemotherapy infusion for an hour and then an infusion of a different chemotherapy drug for 90 minutes. Finally, he receives another antiemetic infusion, this one for 15 minutes.

Step 1: Assign Code for Primary Service

When an encounter involves multiple infusions, you should first determine the main therapy. For the primary service, report the infusion that represents "the key or primary reason for the encounter, regardless of the order that the injections occur," says Rhonda Buckholtz, CPC, practice administrator at Wolf Creek Medical Associates in Oil City, Pa.

Translation: The first infusion isn't necessarily the initial service. Staff may perform the "initial" IV infusion as the second or third therapy.

How the term works: In the above scenario, the patient's primary reason for the visit is the chemotherapy. So, you should consider the chemotherapy infusion--not the hydration or the antiemetic infusion therapy--the initial service.

Using the chemotherapy's duration--one hour--you should select 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). If the patient had received the first chemotherapy agent for more than an additional 30 minutes after the first hour, you would also assign +96415 (... each additional hour, 1 to 8 hours [list separately in addition to code for primary procedure]).

Step 2: Report Sequential Therapy With Add-on Code

You should also use an add-on code for the secondary or sequential infusion. "Sequential infusions immediately follow the initial," Buckholtz says.

Guideline: Report a sequential infusion only one time for the same infusate. "If there is more than one substance in the bag, you would only use the code once."

CPT classifies sequential chemotherapy infusions as +96417 (... each additional sequential infusion [different substance/drug], up to 1 hour [list separately in addition to code for primary procedure]). Because the case study involves "an infusion of a different chemotherapy drug for 90 minutes," you should assign 96417.

Although 96417's descriptor specifies "up to 1 hour," you should report only one unit of this code for the 90-minute infusion. Why: You need more than 30 minutes to code an additional hour, so for two units, you would need to pass the 90-minute mark or have at least a 91-minute infusion.

Step 3: Count Other Admins as Subsequent

 Now that you have coded the chemotherapy potions of the above encounter, look at the other infusion services--the hydration and the antiemetics. When staff use different techniques to administer chemotherapy, you should "report separate codes for each parenteral method of administration employed," states CPT's chemotherapy administration introductory notes. Therefore, you should separately report the hydration and the antiemetic therapies.

Key: Treat these infusions as add-on services. When staff perform multiple services during a single encounter, once you assign the "initial" code, you should report all other services with the "subsequent" or "each additional" codes, Parman says.

Here's how: You already used an initial infusion code: 96413. So stick with add-on codes for the hydration and antiemetics.

• For the 45-minute hydration service, assign +90761 (Intravenous infusion, hydration; each additional hour, up to 8 hours [list separately in addition to code for primary procedure]).

• Report the first antiemetic administration as a medication infusion with +90767 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion, up to 1 hour [list separately in addition to code for primary procedure]).

• For the second antiemetic, use push code +90775 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [list separately in addition to code for primary procedure]). You need a push code because the second antiemetic took 15 minutes, and you report a push for infusions of 15 minutes or less.

Step 4: Check Payer's Modifier 59 Rule

In summary, you would report the case study with the following codes:

• 96413--one-hour chemotherapy infusion

• +96417--90-minute infusion of second chemotherapy agent

• +90761--45 minutes of hydration

• +90767--40-minute antiemetic infusion

• +90775--15-minute push of second antiemetic.

But this list raises an additional question. "When coding infusions, injections, hydration and chemotherapy administration, do I need to use modifier 59 (Distinct procedural service)?" asks Anita Mulligan, CPC, billing manager for the department of pediatrics at Albany Medical College in New York.

According to CMS, "it does not appear that modifiers will be required," Parman says. The National Correct Coding Initiative, version 12.0, does not bundle subsequent or each- additional codes into initial infusion codes. Only "initial codes bundle other initial codes," she says. And the edits do not include 90761 in 96413.

But payers may still require you to append modifier 59 to medically necessary hydration (90761) in addition to chemotherapy (96413). You should use modifier 59 "to indicate that hydration was provided prior to or following chemotherapy," recommends the American Society of Clinical Oncology (ASCO).

"Hydration provided at the same time as chemotherapy to facilitate drug delivery is not separately reportable," states ASCO in "2006 FAQs on Coding for Drug Administration Services and Other Coding Changes from the 2006 Physician Fee Schedule."

Note: For more answers to common drug administration coding questions, see www.asco.org/asco/downloads/FAQs_for_2006_Drug_Administration_122705.pdf.