Chemotherapy and Nonchemotherapy: Bundling and Unbundling of Services and Supplies

Medicare has specific regulations regarding bundling and unbundling of chemotherapy services.

Several HCPCS and/or CPT codes are covered by Medicare but there are also services that Medicare bundles into the payment for other related services.

Separate payment is never made for routinely bundled services and supplies.

If a physician is reimbursed for any other physician Medicare Physician Fee Schedule (MPFS) service rendered on the same day as an injection service, the injection service is bundled and will not receive a separate reimbursement.

Example: A beneficiary receives an evaluation and management (E/M) service (CPT 99221 - initial hospital care) and an injection service (CPT 96365 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour) on the same day. The E/M (CPT 99221), a code included within the MPFS, will be paid; however, the injection code (CPT 96365) is bundled into the E/M code and is not separately payable.

A therapeutic, prophylactic, or diagnostic intravenous infusion or injection, other than hydration, is used for the administration of substances and drugs. The fluid used to administer the drug or drugs is incidental hydration and is not separately payable except in certain circumstances.

Example: An infusion administered to a beneficiary with dehydration with documentation to support the medical necessity of the service, may be payable.

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; and
  • Preparation of chemotherapy agent or agents.

Example: A beneficiary received chemotherapy and an infusion service (HCPCS J7050 - infusion, normal saline solution, 250 cc) on the same day. The infusion service is not separately payable as it is bundled into payment for the chemotherapy service.

Example: A common Comprehensive Error Rate Testing (CERT) finding relates to Infliximab (HCPC J1745). Providers will bill the saline used with the Infliximab injection separately. In these cases, the saline would not be separately billable as reimbursement is bundled into the payment for the Infliximab code.

In addition to the chemotherapy administration or nonchemotherapy injection and infusion services performed, a provider may bill for a significantly separately identifiable E/M service performed on the same day. Bill the appropriate E/M code and append modifier 25 to it. For an E/M service performed on the same day, a different diagnosis is not required.

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Last Updated Fri, 14 Feb 2020 08:39:09 +0000