Childhood Cancer: Code This Case With Care
There’s no room for error when billing for pediatric oncology services.
We never want to think about a child being diagnosed with cancer. Usually, adults are the ones who come into the oncology office with breast, colon, or lung cancer. Childhood cancer is still somewhat rare, but over 15,780 children in the U.S. are diagnosed annually, 300,000 worldwide, and one in 285 children is diagnosed before age 20, according to the American Childhood Cancer Organization.
The most common types of childhood cancer include, but are not limited to, leukemias (e.g., acute myeloid, acute lymphoblastic being the two most common in children), nervous system tumors (brain being the most common), kidney cancer, and lymphomas (Hodgkin and Non-Hodgkin). Leukemia is the most common type and involves a very extensive and lengthy treatment plan — generally, at least three years are spent on chemotherapy, transfusions, social work, and any hospital stays or surgeries. In rare cases, a child may receive a stem cell or bone marrow transplant from a match.
It is a very difficult ordeal for the families and loved ones involved. We see the spaghetti suppers and web pages asking for donations for treatment. Cancer places enormous financial and emotional strain on families. As medical coders, it’s our job to make sure the medical services are documented and billed correctly to prevent unnecessary burdens.
To gain a basic understanding of pediatric oncology coding, consider the following case scenario for a pediatric patient diagnosed with cancer and the health services that follow.
Diagnostic: Bone Marrow and Biopsy
A 5-year-old, female patient was up late at night crying with a fever and complaining of joint pain. The patient’s parents took her to their pediatrician the next morning. The patient was pale and tired and her belly also had some swelling. The father did have a discussion with the provider that she was a picky eater but was now eating less than usual. The pediatrician examined the patient and took note of the abdominal swelling and enlarged lymph nodes. The pediatrician ordered labs, including a blood smear and complete blood count (CBC), to determine the patient’s white blood cell count (WBC).
The lab results showed a high WBC count and not enough red blood cells and platelets. This is not always an indication of cancer — hematological disorders are possible — but leukemia is the most likely diagnosis.
The patient was referred to our pediatric oncology clinic, where an oncologist performed a diagnostic bone marrow aspiration and biopsy to make a clinical diagnosis.
38222 Diagnostic bone marrow; biopsy(ies) and aspiration(s)
In many cases, an aspiration with a biopsy will give the clearest diagnosis of cancer. CPT® 38222, as well as 38220 Diagnostic bone marrow; aspiration(s) and 38221 Diagnostic bone marrow; biopsy(ies), require a laterality modifier to indicate left, right, or bilateral (LT, RT, or 50), so this information must be documented in the provider’s note.
The samples are usually taken from the back of the pelvic (hip) bones, but sometimes they are taken from the front of the pelvic bones or from other bones. Before the tests, the skin over the hip bone is cleaned and numbed by injecting a local anesthetic or applying a numbing cream. In most cases, the child is also given other medicines to make them drowsy or sleep during the tests. The aspiration is done first, which involves inserting a thin, hollow needle into the bone and using a syringe to suck out (aspirate) a small amount of liquid bone marrow. A bone marrow biopsy is usually done just after the aspiration. A small piece of bone and marrow is removed with a slightly larger needle that is pushed down into the bone.
Dealing With a Confirmed Diagnosis of Cancer
In this case, the pathology report confirmed the patient has acute lymphoblastic leukemia, which is the most common type of childhood leukemia. The set of leukemia codes has a simple formula: C91.00 is active, C91.01 is remission, and C91.02 is relapse. This also applies to the other types of leukemia. It’s important to read the provider’s note to see the progress of the leukemia, as it will determine the next course of treatment for the patient, including the type of drugs they will be given and the frequency. Patients in remission typically have less intense treatment; and if they go long enough without relapse, eventually they may no longer need chemo. There is, of course, always a chance leukemia will relapse, which is why this type of cancer is so difficult to treat.
As expected, the family is devastated by the news. Their child’s life is now going to involve lots of visits to the hospital and practice for the next few years, and the outcome is uncertain. Social workers are implemented to assist families in the process and even spend one-on-one time with the patient to help them understand and process their diagnosis.
The following social work codes have a National Correct Coding Initiative (NCCI) edit with the provider’s evaluation and management (E/M) visit, if performed on the same day.
96156 Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)
This visit is not time-based and is usually a first visit with the patient to assess them and the family and evaluate their needs and goals. The rest of the codes are based on time, and a minimum of 16 minutes must be spent with the patient and/or the patient’s family:
96158 Health behavior intervention, individual, face-to-face; initial 30 minutes
+96159 each additional 15 minutes
96167 Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
+96168 each additional 15 minutes
96170 Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
+96171 each additional 15 minutes
A typical visit with the patient and their family is 30 minutes, billed as 96167. If they meet for 45 minutes, bill 96167, 96168.
Time for Infusion Treatment
The provider and social worker explain the treatment process to the family; the first treatment will be an intravenous infusion of chemotherapy and/or other therapeutic drugs. This is the most difficult part of the process, as many children are afraid of needles and shots, and it does take a few nurses to calm the child and begin the infusion.
The hierarchy of infusion codes, shown in Figure A, can be confusing and complicated in the beginning, but knowing the start and stop times, the drugs, and when to bill hydration time is helpful.
Typical chemotherapy drugs infused include etoposide, cyclophophamide, cytyrabine, vincristine, vinblastine, doxarubicin, bleomycin, pegasparginase, irinotecan, and vinorelbine. There is an extensive list available online (e.g., drugs.com) that explains each drug, how it works, and for how long it is typically infused. Multiple chemotherapy drugs can be billed one after the other, or even done as a chemo push.
The criteria for a chemo infusion require the infusion to be done for a minimum of 16 minutes. Anything less than 15 minutes is a push, according to CPT® guidelines. Each drug must have start and stop times listed unless the provider is doing a push for 1 minute. Most of the time, patients receive one to six drugs in the office.
IV infusions and pushes follow the same time guidelines, but the list of drugs is much longer, including fosaprepitant, immunoglobin IVIG, Benadryl®, Zofran, lorazepam, and anything else that supports the patient during chemotherapy. Patients often experience various side effects from chemotherapy drugs, such as nausea and vomiting, and these drugs may be administered to combat these side effects. Sometimes a push of the same drug can be given twice, but you can only bill two units if they were given at least 30 minutes apart.
Hydration can be given for 30 minutes or more and must always have an end time. Patients also often experience dehydration, anemia, fatigue, low platelets, sore mouth, and loss of appetite, and need electrolytes restored to their body. Most hydration is a mixed bag, or bolus, of saline/lacerated ringers.
The patient comes in for her first treatment and needs a few different drugs to start chemotherapy. The provider ordered the following drugs, and the nurse documented the start and stop times of each:
Cyclophosphamide 9:00-11:30 Vincristine 8:50-8:55
Zofran 12:45 Etoposide 11:30-12:00
Benadryl 1:00 Bolus 8:30-9:00, 1:05-2:45
Code the Drug Administrations
Regardless of the order in which the drugs were given to the patient, you must code the drugs according to their hierarchy. Always start with the chemotherapy drugs given for 30 minutes or more and the drug with the longest infusion time (if applicable). All drugs administered are HCPCS Level II J codes. The dosage will vary from patient to patient and is often pre-mixed in the pharmacy.
The longest drug infused (2.5 hours) was the cyclophosphamide (J9070).
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
+96415 Each additional hour
Etoposide was the next chemo drug infused for 30 minutes.
+96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour
Vincristine (J9370) is another chemo drug that was given but only infused for 5 minutes.
+96411 Chemotherapy administration; intravenous, push technique, each additional substance/drug
We cannot bill for chemo administration via IV push (96409) with 96413 unless two separate sites were used for chemotherapy/infusion therapy, which is more likely to be seen in a hospital setting.
Next was the IV infusion of fosaprepitant (J1453), which is not a chemo drug.
+96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour
CPT® code 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour would not be correct unless the drug was given at a separate site.
Benadryl (Diphenhydramine, J1200) and Zofran (Ondansetron, J2405) were given for 1 minute each, respectively. IV pushes do not require stop times if done for 1 minute — it’s still a push. These codes are toward the bottom of the hierarchy. You would bill two units; one unit for each drug (+96375 x 2).
+96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug
The hydration (J7050) is last and given at the beginning and end of the infusion: 30 minutes and 40 minutes, respectively, for a total of 70 minutes. You can bill for hydration if it’s administered for 30 minutes or more and there are documented start and stop times. It cannot overlap any drugs that are higher on the hierarchy.
+96361 Intravenous infusion, hydration; each addition hour
CPT® add-on code +96361 is typically used when billing for multiple drug administrations. CPT® code 96360 is for hydration given alone.
List ICD-10-CM code Z51.11 Encounter for antineoplastic chemotherapy as the primary, followed by the cancer diagnosis (in this case, C91.00 Acute lymphoblastic leukemia not having achieved remission). List any other conditions the patient has that are addressed by the provider after these two codes.
This patient may receive several sessions of various chemotherapy drugs, infusions, or even subcutaneous injections.
96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular is not part of the hierarchy.
96450 Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture involves a lumbar puncture to sample the patient’s spinal fluid and infusion of a chemo drug, such as methotrexate or cytarabine, around the patient’s spinal cord.
96425 Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump involves an Ommaya port (surgery is involved to insert the port) that allows the physician to inject chemotherapy drugs that have difficulty crossing the blood-brain barrier. This is more common in patients who are diagnosed with a brain or spinal cancer. The port is similar to a chest port that makes giving chemotherapy drugs easier on the patient to avoid accessing the same veins and sites over and over again.
96416 Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump is a type of long chemotherapy given for eight hours or more. It typically involves attaching a bag to the patient that administers continuous chemotherapy to the patient over a period of several days. The patient comes in periodically to have the dose monitored and adjusted as needed by the provider. Some forms of leukemia may be more stubborn and require this type of method. This code is not on the infusion hierarchy.
+96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion is not time-based, and any number of drugs can be given to the patient at one time, but you may only bill this code once per date of service.
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic is not part of the infusion hierarchy and is given in a similar fashion as 96372.
36430 Transfusion, blood or blood components identifies blood and blood products given to patients who are anemic. One of the many side effects of chemotherapy is a low red blood cell count. Many of these products come from blood banks, so it is vital for the documentation and provider’s orders to be as accurate as possible.
It’s essential to be familiar with these treatments in order to code the patient’s treatment correctly, as these are high-dollar charges that will be scrutinized by the insurance companies. Having a strong compliance team, revenue integrity, and coding and billing staff that knows these rules inside and out will lead to fewer denials.
In addition to all the infusions this patient receives, they may also be placed on a home regimen of oral chemotherapy that the parents will have to administer to their child. This would count as prescription drug monitoring for a high-risk drug, and it’s not uncommon to bill a Level 4 or 5 E/M visit in this setting.
Code Status of Cancer
If the patient responds to the chemotherapy, she will likely reach remission. The time this takes varies for each patient. A bone marrow biopsy can confirm a diagnosis of C91.01 Acute lymphoblastic leukemia, in remission.
Remember: If stop times are not present for drugs that are not IV pushes or hydration, query the nurse. Bill only one initial code (96413, 96409, 96365, 96374, 96360) per visit for administration up to 1 hour 30 minutes.
Add-on codes +96415, +96366, and +96361 are billable when a drug is given for 1 hour and 31 minutes or longer. One unit per hour is given once 180 minutes is reached. Drugs in the lower hierarchy receive one unit for each 60 minutes given to the patient.
Report one unit of add-on code +96417 or +96367 for every 60 minutes a drug is given to the patient.
CPT® codes 96411, 96375, and 96376 do not require stop times because they are IV pushes. IV pushes can be done for 15 minutes or less.
Some patients have long-lasting remission, but in the event of a relapse, the patient may return for more intense chemotherapy or even qualify for a bone marrow transplant, generally performed at a large hospital in a major city. The provider will need to coordinate with this hospital to find a bone marrow match, and social workers will need to help find tools to aid the patient with transportation and programs that assist with costs of treatment.
At the end of treatment, should the patient remain in remission, she will continue to be seen by the provider every few months for several years. When the provider determines there is no clinical evidence of any remaining disease, you will report Z85.6 Personal history of leukemia.
Eventually, our young patient will only need to see the provider once a year, for which you may bill a Level 3 or 4 E/M visit, depending on medical decision making or tests and procedures reviewed.
This is just one scenario for one patient out of many who are seen annually for cancer treatment. No two patients will have the same treatment plan, and every patient’s journey is somewhat different from the next. The hardest part is knowing that not every patient will survive, but the providers and teams that work with these patients do their very best each day to make their patients’ lives meaningful.
American Medical Association, CPT® 2022 code book