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Guidelines for Chemotherapy Administration Codes

Guidelines for Chemotherapy Administration Codes

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 monoclonal antibody agents, and other biologic response modifiers. The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration. If a significant separately identifiable evaluation and management service is performed, the appropriate E/M code should be reported utilizing modifier 25 in addition to the chemotherapy code. For an evaluation and management service provided on the same day, a different diagnosis is not required.

Coding for Nonchemotherapy Injections and Infusion Services

While reporting for chemotherapy administration and nonchemotherapy injections and infusion services follow these coding guidelines:

  • Look for exceptions in subsection C for CPT code 90772.
  • When administering multiple infusions, injections or combinations, the physician should report only one ‘initial’ service code 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, the A/B MAC (B) shall deny the second initial service code unless the patient 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, instruct the physician to report with modifier 59.
  • The CPT includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis. Allow only one concurrent infusion per patient per encounter. Do not allow payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record.
  • For chemotherapy administration and therapeutic, prophylactic and diagnostic injections and infusions, an intravenous or intra-arterial push is defined as an injection in which the healthcare professional is continuously present to administer the substance/drug and observe the patient; or an infusion of 15 minutes or less.
  • The physician may report the infusion code for ‘each additional hour’ only if the infusion interval is greater than 30 minutes beyond the 1-hour increment. For an example if the patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the physician would report the ‘initial’ code up to 1 hour and the add-on code for the additional 45 minutes.
  • Several chemotherapy administrations and nonchemotherapy injection and infusion service codes have the following parenthetical descriptor included as a part of the CPT code, ‘List separately in addition to code for primary procedure.’ Each of these codes has a physician fee schedule indicator of ‘ZZZ’ meaning this service is allowed if billed with another chemotherapy administration or nonchemotherapy injection and infusion service code.
  • Do not interpret this parenthetical descriptor to mean that the add-on code can be billed only if it is listed with another drug administration primary code. For example, code 90761 will be ordinarily billed with code 90760. However, there may be instances when only the add-on code, 90761, is billed because an ‘initial’ code from another section in the drug administration codes, instead of 90760, is billed as the primary code.
  • Pay for code 96523, ‘Irrigation of implanted venous access device for drug delivery systems,’ if it is the only service provided that day. If there is a visit or other chemotherapy administration or nonchemotherapy injection or infusion service provided on the same day, payment for 96523 is included in the payment for the other service.

Coding Guidelines for E/M Services Furnished on the Same Day

Do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code 99211 when it is billed with a diagnostic or therapeutic injection code. Physicians providing a chemotherapy administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill using modifier 25. The A/B MACs (B) pay for evaluation and management services provided on the same day as the chemotherapy administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meet the requirements, even though the underlying codes do not have global periods. If a chemotherapy service and a significant separately identifiable evaluation and management service are provided on the same day, a different diagnosis is not required.

Legion Health Care Solutions is a leading medical billing company that can assist you in revenue cycle functions for your practice. We referred Medicare Claims Processing Manual Chapter 12 to discuss guidelines for chemotherapy administration codes. For any assistance in oncology coding or overall billing for oncology services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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