Oncology & Hematology Coding Alert

Keep count on total hours of infusion and check substances infused.

Reporting for multiple infusions may be a common challenge in your practice. What can be perplexing is the administration of two or more chemotherapeutic substances in sequence or infusion of hydration concurrent to chemotherapy.  Here is how you can meet the challenges for multiple infusions.

Report 96413 for First Hour of Infusion

When reporting an infusion of any chemotherapy substance, you will have to report the initial one hour of infusion with 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). 

Use only once per patient: You’ll use code 96413 only once per patient encounter unless the two chemotherapeutic substances were provided during two different sessions of administration on the same day or through a separate IV site.

Look For Add-On Codes for Additional Hours of Infusion

If the administration of the same substance was continued beyond the first hour of administration, you’ll have to report the administration using the add-on code +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]). You will report one unit of +96415 for every additional hour of administration. 

You can report multiple units of +96415: Look for how much time beyond the first hour the infusion continued. As per CPT® time rules, you report +96415 “for infusion intervals of greater than 30 minutes beyond 1-hour increments”. For example, if the time spent in the infusion beyond the first hour of administration is one and 31 minutes, you report two units of +96415.  “Nothing less than 31 minutes would qualify for reporting the additional hour code,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc.

Do Not Count Time When Drug Was Stopped

You may come across circumstances when the physician begins the infusion of chemotherapy, which continues for two hours, and then the physician stops it for a few minutes before beginning it again for an additional hour. In this case, you report code 96413 for the first hour and +96415 for the second and third hour. You should count only the time the infusion of the same drug was being administered or “running”-- the time during which the drug is stopped cannot be counted into the total infusion time.

Remember: You can bill only one “initial” code per encounter. So you don’t report 96413 for the second start-up. You simply report +96415 again for additional infusion intervals. 

Be Specific For Infusion of Second Substance

Your physician may be performing infusion of two anti-neoplastic substances for a patient. For the second substance, you report the first hour of administration for the second drug with the add-on code +96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion [different substance/drug], up to 1 hour [List separately in addition to code for primary procedure]). For the administration of the second substance beyond the first hour of administration, you’ll again report +96415 for the additional hours beyond the first of the second drug. 

Example: If your clinician administered the second substance for two hours, you’ll report +96417 for the first hour and +96415 for the additional hour of administration.

Check for Any Concurrent Hydration

It isn’t uncommon to see a hydration documented with an infusion of the chemotherapeutic substance. If your clinician also ordered and hydration was provided during the infusion in the example above, you’ll have to report this with the add-on code +96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]) for every hour of hydration administered. Also note that you cannot use 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) for reporting hydration with a concurrent infusion.  “This add-on code carries the same additional hour rule for subsequent hours, infusion time exceeding 30 minutes beyond the 1-hour increment,” says Loya.

Don’t Forget the J Codes

You will have to report the supply of the substances used for the infusion separately using the appropriate HCPCS J code. 

Note: You should bill these J codes in terms of number of units used for the infusion and not one unit for the entire vial. For example, if a 100-mg vial of Remicade was used, you report J1745 (Injection infliximab, 10 mg) for every ten milligrams used. Therefore, you report ten units (J1745x10) if for example the entire 100mg vial of Remicade was infused.