Coder's Cranium / CPT 2011

Is 96413 + 96365 OK?

Coding is all about applying standardized code sets to situations that don’t always qualify as “standard.” The good news is that authoritative coding resources sometimes address even those encounters you don’t handle on a daily basis. Test your skills with these two scenarios and see whether your responses match the official rules.

Challenge 1: Staff administers a non-chemotherapy therapeutic drug via one IV infusion site, and then following oncologist orders based on protocol, administers chemotherapy intravenously via a second IV site. Should you report the chemotherapy admin or the non-chemotherapy admin as the initial code?

Solution 1: Challenge 1 presents a trick question. You should report initial codes for both the chemotherapy and non-chemotherapy infusions.

CPT guidelines state, “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,” notes Gwen Davis, CPC, associate with Washington-based Derry, Nolan, and Associates.

Citing this same rule, Tracy Helget, CPC, in the business office of Medical Associates of Manhattan in Kansas, notes, “The easiest way to think of this is, if we are making more than one stick to the patient, we bill more than one initial code.”

Many payers indicate that when you report two initial codes because each requires a separate access site, you should append modifier 59 (Distinct procedural service). So you may need to append modifier 59 to the secondary “initial” code to indicate the separate IV sites for each infusion in this case. For example, your claim may include the following:

  • 96413 – Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
  • 96365-59 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.

Challenge 2: Documentation indicates your oncologist participated in...

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February 4, 2011
Coding Challenge / modifier 53

Oncology Coding: Determine the Proper Adverse Reaction Code

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for...

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June 3, 2010
Hot Coding Topics

Ace CPT and ICD-9 Coding for Intra-Arterial Cases

Whether liver neoplasm is primary or secondary will change your coding.

Good news: You can apply many of the same rules you already know for intravenous chemotherapy coding to intra-arterial coding, too. So take your chemo coding expertise to the next level by adding intra-arterial skills to your arsenal.

Start here: For intra-arterial (IA) chemotherapy, you should choose from the following codes, says Gwen Davis, CPC, associate with Washington-based Derry, Nolan, and Associates.

  • 96420 — Chemotherapy administration, intra-arterial; push technique
  • 96422 — … infusion technique, up to 1 hour
  • +96423 — … infusion technique, each additional hour, (List separately

...

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May 20, 2010
Coding Challenge / Oncology

Oncology Coding: Day 1 of FOLFOX4 Regimen

Here’s the key to concurrent infusion coding. Question: What are the appropriate codes for the first day of the FOLFOX4 regimen? Answer: You should base your final coding decision on the documentation and the exact services your practice provides. But as a starting point, the FOLFOX4 regimen typically involves the patient receiving Oxaliplatin and folinic acid concurrently [...] Related articles:

  1. Oncology Coding Challenge: When Infusion Runs Long Question: The oncologist ordered a 90-minute chemotherapy infusion service,...
  2. Infusion Coding Education: Remicade Coding Hint: Watch for ‘add-ons’ during Remicade sessions Question:...
  3. Do I Use a Chemo Code for Zevalin Therapy?Question: When I looked up Zevalin, I found out it’s...

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February 11, 2010
Coding Challenge

Infusion Coding Education: Remicade

Coding Hint: Watch for ‘add-ons’ during Remicade sessions Question: An established patient with a plan of care in place for his Crohn’s disease of the ileum reports to the gastroenterologist for a Remicade infusion. The infusion started at 10:00 a.m. and ended at 11:42. The patient reported nausea during the infusion, so the gastroenterologist administered 200 mg of Benadryl from 10:41 [...] Related articles:

  1. Oncology Coding Challenge: When Infusion Runs Long Question: The oncologist ordered a 90-minute chemotherapy infusion service,...
  2. CODING CHALLENGE: Is V58.11 Right for Patient Not on Chemo? Question: When you use a chemo admin code for...
  3. Gastroenterology Coding Education: Bravo Cap Placements Question: A new patient reports to the gastroenterologist with complaints...

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November 9, 2009