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 [...]