Chemotherapy Administration Billing - JE Part A
Chemotherapy Administration Billing
The American Medical Association's (AMA) Current Procedural Terminology (CPT) offers three categories of chemotherapy administration and nonchemotherapy injections and infusions:
- Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy); and
- 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.
Access the below related information from this page.
- Administration Hierarchy
- Bundled/Packaged Services
- Billing Guidance
- Redetermination Examples
According to CPT, infusions are primary to pushes, which are primary to injections. The administration and initial code hierarchies are to be followed by facilities and supersede parenthetical instructions for add-on codes that suggest an add-on 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.
For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, a push is defined as:
- 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.
If performed to facilitate the 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)
Payment for the above is included in the payment for the chemotherapy administration service.
Also, the administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration.
Outpatient Administration and Drug
Claims processing of the chemotherapy administration code is supported by the billed, approved chemotherapy drug. If a drug is not billed along with the administration code, the administration will currently deny. Effective October 15, 2018, the administration code will return to provider (RTP) if an approved chemotherapy drug is not billed on the claim.
For additional information on billing a drug that was supplied by the patient, or for free, refer to Patients Supplied Donated or Free-of-Charge Drug Medicare Coverage Article.
Some chemotherapeutic agents and other therapeutic agents require pre- and/or post-hydration to be given in order to avoid specific toxicities. 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 same IV access. If hydration is an integral part of the chemotherapy administration, it may not be billed separately.
To bill for declotting a catheter or port, use CPT 36593.
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 initial code is the code that 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 of a subsequent or concurrent nature, even if it is the first such 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.
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 has two IV lines per protocol. For these separately identifiable services, report modifier 59.
Sequential Infusion or Injection
Report CPTs 96366, 96367, 96375 to identify a therapeutic, prophylactic, or diagnostic drug infusion or injection, if administered as secondary, or a subsequent service, in association with CPT 96413 when through the same IV access. All sequential services require that there be a new substance or drug, except that facilities may report a sequential intravenous push of the same drug using CPT 96376.
Evaluation and Management (E/M) on Same Day
If a significant separately identifiable E/M service is performed, the appropriate E/M code should 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.
|Redetermination Scenario||Redetermination Decision||Explanation of Decision|
|In a post-payment review, RAC found that CPT 96413 was denied by a system edit, and therefore, subsequently denied add-on CPT codes 96361 and 96365. Provider appealed all three codes||Fully Favorable||Upon appeal, Noridian found chemotherapy administration charge payable, due to Medication Administration Record (MAR) supported an approved chemotherapy drug was administered; therefore, add-on charges were also approved|
|Claim billed with HCOCS J0894, Decitabine, and CPT 96413. Provider appealed denial of CPT 96413||Partially Favorable||
Decitabine is not billable with chemotherapy administration per Noridian Chemotherapy Administration Coverage Article. Noridian corrected CPT from 96413 to *96365 and paid that line-item
*Documentation must support that drug was infused over a minimum of 16 minutes, otherwise a push code would have been more appropriate
|Claim billed with HCPCS J9035, Bevacizumab, and CPT 96413. Provider appealed CPT 96413||Unfavorable||Claim was originally denied by Noridian pre-payment review. Upon appeal, Noridian determined that drug was noted to be investigational and associated with frequent fatal side effects when given for certain diagnoses, according to FDA. Per CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.3 "If a medication is determined not to be reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the A/B MAC (B) or DME MAC excludes the entire charge (i.e., for both the drug and its administration)."|
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.3
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.5(D)
Last Updated Thu, 20 Feb 2020 07:40:37 +0000