Chemotherapy and Nonchemotherapy

The American Medical Association's (AMA's) Current Procedural Terminology (CPT) offers three categories of chemotherapy administration and nonchemotherapy injections and infusions:

  1. Hydration;
  2. Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and
  3. Chemotherapy administration.

Chemotherapy administration codes apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as some specific monoclonal antibody agents, and certain biologic response modifiers.

Chemotherapy administration is considered highly complex and requires physician or qualified health professional work and monitoring well beyond the level of the therapeutic, prophylactic, and diagnostic injections and infusions code series (96360-96379) due to the high incidence of potentially adverse reactions for the patient.

This service typically requires direct supervision from qualified health professionals and/or clinical staff with advanced practice training in the special considerations of preparation, dosage, and disposal and often involves frequent monitoring of the patient and conferring with a physician.

For chemotherapy administration and therapeutic, prophylactic, and diagnostic injections and infusions, a push is:

  • Injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or infusion of 15 minutes or less.

Per CMS update, January 2, 2025, Internet Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.5; Medicare may consider multiple factors when determining if the level of intensity for a complex drug administration service has been met, rather than just the drug name alone.

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Definitions

Initial Code

CPT codes 96360, 96365, 96374, 96409, and 96413 describe "initial" service codes. For a patient encounter only one "initial" service code may be reported. If more than one "initial" service code is billed per day, Noridian will deny the second initial service code, unless the beneficiary has to come back for a separately identifiable service on the same day or unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites per protocol. For these separately identifiable services, append modifier 59.

Sequential Infusion

Sequential infusion is an infusion or IV push of a new substance or drug following a primary or initial service. Report CPTs 96366, 96367, 96375 to identify a therapeutic, prophylactic, or diagnostic drug infusion or injection, if administered as a secondary, or a subsequent service, in association with CPT 96413 when through the same IV access. All sequential services require that a new substance or drug is provided. (Exception: Facilities may report a sequential intravenous push of the same drug using code 96376)

Concurrent Infusion

Concurrent infusion is a new substance or drug infused at the same time as another substance or drug. This service is not time based but rather reported once per day (encounter), regardless of whether an additional new drug or substance is administered concurrently.

Multiple Infusion Reporting

Multiple infusions individually prepared and administered are recognized and reported as individual administrations. When administering multiple infusions, injections, or combinations, only one "initial" service code should be reported, unless protocol requires that two separate IV sites must be used.

The Physician may report the infusion code for "each additional hour," only if the infusion interval is greater than 30 minutes beyond the one-hour increment.

  • For example, if the patient receives an infusion of a single drug that lasts one hour and 45 minutes, the physician reports the "initial" code up to one hour and add-on code for additional 45 minutes.

Bundled/Packaged Services

  • Medicare has specific regulations regarding bundling and unbundling of chemotherapy services
  • Medicare covers several HCPCS and/or CPT codes; however, may bundle other related services into payment
  • Separate payment never made for routinely bundled services and supplies

If performed to facilitate chemotherapy or non-chemotherapy infusion or injection, the following services and items are included and are not separately billable.

  • Use of local anesthesia
  • Intravenous (IV) access
  • Access to indwelling IV, subcutaneous catheter or port
  • Flush at conclusion of infusion
  • Standard tubing, syringes, and supplies
  • Preparation of chemotherapy agent(s)
  • Incidental Hydration

Billing Guidance-Outpatient and Facility

CPT codes 96360-96379, 96401-96425, and 96521-96523 are reportable by physicians for services performed in physicians' offices. These drug administration services shall not be reported by physicians for services provided in a facility setting such as a hospital outpatient department or emergency department.

Drug administration services performed in an Ambulatory Surgical Center (ASC) are not separately reported by physicians. Hospital outpatient facilities may separately report drug administration services when appropriate.

Drug Codes and Descriptions

96365-96379 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions

  • 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
    • 96366 each additional hour (List separately in addition to code for primary procedure)
    • 96367 additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)
  • 96372 Therapeutic, Prophylactic, or Diagnostic Injection (specify substance or drug); subcutaneous or intramuscular
  • 96374 Therapeutic, Prophylactic, or Diagnostic Injection (specify substance or drug); intravenous push, single or initial substance/drug
    • 96375 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)
    • 96376 Therapeutic, Prophylactic, or Diagnostic Injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug provided in a facility (List separately in addition to code for primary procedure)**** REPORTED BY FACILITIES ONLY
  • 96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion

96401-96417 Injection and Intravenous Infusion Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

  • 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
  • 96402 Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic
  • 96409 Intravenous, push technique, single or initial substance/drug
    • 96411 Intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)

Outpatient Billing

  • In the outpatient office (non-facility) setting, the initial code is what best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur.
  • If an injection or infusion is subsequent or concurrent in nature, even if it's the first service within that group of services, then a subsequent or concurrent code should be reported. For example, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code.

Facility Billing

Administration Hierarchy
  • According to CPT, for facility reporting, an initial infusion is based on the stated hierarchy. "The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services, which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.
  • This hierarchy is to be followed by facilities and supersedes parenthetical instructions for add-on codes that suggest an add-on code of a higher hierarchical position may be reported in conjunction with a base code of a lower position.
  • For example, the hierarchy will not permit reporting CPT 96374 with 96360, as 96374 is a higher order code; the IV push is primary to hydration. In addition, both codes are considered "initial codes" and only one "initial code" may be billed per day.

Additional Notes

Hydration

Some chemotherapeutic agents and other therapeutic agents require pre- and/or post-hydration to be given in order to avoid specific toxicities. In these instances, documentation must support the medical necessity for pre- and/or post-hydration. A minimum time duration of 31 minutes of hydration infusion is required to report the service; however, the hydration CPT codes 96360 or 96361 are not used when the purpose of the IV fluid is to "keep open" an IV line prior or subsequent to a therapeutic infusion, or as a free-flowing IV during chemotherapy or other therapeutic infusion.

Report CPT 96361 to identify hydration if it is administered as secondary, or a subsequent service, in association with 96413 through the same IV access. If hydration is an integral part of the chemotherapy administration, it may not be billed separately.

Evaluation and Management (E/M) - Same Day

The drug and chemotherapy administration CPT codes 96360-96379 and 96401-96425 are valued to include the work and practice expense of CPT code 99211. Although CPT code 99211 is not reportable with chemotherapy and nonchemotherapy drug administration HCPCS/CPT codes, IF a significant separately identifiable E/M service is performed, the appropriate E/M code may be reported using modifier 25 in addition to the chemotherapy code.

For an E/M service provided on the same day, a different diagnosis is not required; however, the provider must sufficiently document the medically necessary E/M service and procedure in the patient's medical record to support the billed claim.

Since physicians shall not report drug administration services in a facility setting, a facility-based E/M CPT code (e.g., 99281-99285) shall not be reported by a physician with a drug administration CPT code unless the drug administration service is performed at a separate patient encounter in a non-facility setting on the same date of service.

Miscellaneous

Administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration.

  • Oral Anticancer Drugs and Oral Anti-emetic drugs are considered separate Medicare benefit categories.
  • CMS HCPCS range for chemotherapy drugs and biologicals includes J9000-J9999.
  • Depending on circumstances, chemotherapy and non-chemotherapy drugs may be billed under Medicare Part B or considered a DME benefit.
  • Check drug codes billed to Noridian Part B vs. DME on the Jurisdiction List.
  • For additional information on billing a drug supplied by the patient, donated, or free, refer to Patients Supplied Donated or Free-of-Charge Drug Medicare Coverage Article.

Resources

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