Coding Injections and Infusions for Chemotherapy
Coding injections and infusions of chemotherapy agents often seems a little daunting, but understanding a few foundational definitions and principles can make code selection much easier. Read on to review the basics of injection and infusion coding that apply when reporting the administration of chemotherapy.
Injections administer a substance all at one time for immediate effect. Injections are delivered through various routes of administration including: Intramuscular, subcutaneous, intravenous or intra-arterial.
An infusion is the slow administration of a substance, into a vein, artery or tissue, over time. In some cases the substance is delivered via saline or other solutions. Note: The saline used to facilitate an infusion is incidental to the procedure and not separately reportable as hydration.
An IV or intra-arterial push is an infusion that lasts 15 mins or less.
There are guidelines that govern the selection of the primary or initial procedure reported for injections and infusions.
o Physicians – The initial infusion is the key or primary reason for the encounter regardless of the order in which the substances are administered
o Facilities – Initial infusions are governed by hierarchies (see below)
o Only one initial service code is reported unless two separate IV sites are required. Do not report additional codes for initial services from other groups of service even if the service is the initial service from that group. Use the codes for subsequent or concurrent services instead.
A sequential service is an infusion or push of a new substance following a primary or initial service.
o Exception – Facilities may reports a sequential IV push of the same drug with code 96376
o A concurrent service (+96368) is an infusion of a new substance at the same time as another substance.
o Concurrent services are not time based and may only be reported once per day
o Concurrent hydration may not be reported with any other service
Only the time when a substance is being actively administered is used to calculate infusion time. This time is calculated based on the documented start and stop times. Infusions are billed by the hour. Infusions must run at least 16 mins to count as the first hour. Additional hours are counted only after the infusion time has run at least 31 mins into the next hour. So, for example, a second hour of infusion can be coded once the infusion time equals one hour and 31 mins or 91 mins and a third hour of infusion time can be coded once the infusion time equals two hours and 31 mins or 151 mins.
Injection – no time requirement
15 mins or less – IV push
16-90 mins – Initial hour of infusion
91-150 mins – second hour of infusion
151 - 210 mins - third hour of infusion
Hierarchy of services
When coding for injection and infusion services, selection of the initial service is made based on a hierarchy of services. Infusions are at the top of the hierarchy and are primary to IV pushes which are primary to injections.
IV pushes (IVP)
Injections (Sub-Q, IM)
Hierarchy of substances
The selection of an initial service is also based on a hierarchy of substances. The administration of chemotherapy or other highly complex drugs or biological agents is at the top of the hierarchy and is primary to the administration of therapeutic, diagnostic or prophylactic substances which is primary to the administration of hydration.
Chemotherapy services – (96401 – 96425)
Therapeutic, diagnostic and prophylactic services – (96365 – 96379)
Hydration services – (96360, +96361)
Combining the hierarchies
When multiple substances are administered, the positions in the substance hierarchy (chemotherapy, therapeutic substance, hydration etc.) supersede the positions in the hierarchy of services (injection, push, infusion). Thus, an add-on code for administration of a higher level substance cannot be reported in conjunction with a base code for a lower level substance. The example given in CPT is that code 96376 for an infusion of hydration should not be reported with 96376 which reports an IV push of a therapeutic substance. The reason for this is that although an infusion is higher in the hierarchy of services than an IV push, a therapeutic substance is higher than hydration in the hierarchy of substance.
Chemotherapy Administration Guidelines
The following is a summary of the guidelines specific to the administration of chemotherapy.
· Chemotherapy administration requires direct supervision due to the need to monitor the patient and adjust the infusion rate
· Preparation and disposal of chemotherapy substances is not separately reportable
· Codes for chemotherapy administration are not intended to be reported by physicians or other qualified health care professionals in the facility setting
· Report codes for each method of administration
· Administration of substances (e.g., steroids, anti-emetics), either independently or sequentially, as supportive management for chemotherapy are reported with codes 96360, 96361, 96365 and 96379 as appropriate.
Based on the information above, let’s look at an example of coding for chemotherapy administration.
Manuel, who has prostate cancer, presents to the chemotherapy clinic for treatment. He is given an IM injection of Procrit to prevent anemia. Next he receives an antiemetic via IV infusion from 12:32 pm to 12:58 pm. Then he is infused with his chemotherapy treatment from 1:05 pm to 2:44 pm.
Primary procedure code
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
Rationale: Chemotherapy infusions take precedence in the hierarchy over infusion or injections of therapeutic, prophylactic or diagnostic substances, therefore chemotherapy infusion is the initial (primary) service. Code 96413 reports the first hour of infusion.
Secondary procedure codes
+96415 Chemotherapy administration, intravenous infusion technique; each additional hour
Rationale: Because the chemotherapy infusion lasted 1 hour and 39 minutes, a second hour of infusion can be billed. The second hour is reported with add-on code +96415.
+96367 Intravenous infusion for therapy, prophylaxis or diagnosis; additional sequential infusion of a new drug/substance up to 1 hour
Rationale: The anti-emetic is a new drug. The first hour of sequential infusion of a new substance/drug is reported with add-on code +96367. Although this drug was administered first it is considered a sequential infusion because the chemotherapy administration is the initial service.
96372 Therapeutic, prophylactic or diagnostic injection
Rationale: This reports the Procrit injection. Although this was the first service provided, it falls below the other services in both the services and substances hierarchies, so it must be a secondary code.
For more coding resources, visit the MRA blog here.
For more information on this topic, see this AHIMA resource.
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