Cpt 96366

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mjm41795

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Can somebody please shed some light on proper coding for CPT 96366.

Pt. receives Zofran as a 20 min infusion as well as Taxol for a 3 hour infusion.

I would code as the following

96413
96415 x2
J9265
96367
J2405

Would this be correct? I read the 96366 as additional hours for non-chemotherapy infusions. Please state the source if known.
 
Yes, you are correct.

96413 x 1, 96415 x 2 for the Taxol
96367 x 1 for the Zofran

The 96366 is for each additional hour of a theraputic drug. So if you have a theraputic drug provided for 1 hour and 31 minutes and chemo was NOT given you would charge 96366 x 1, 96367 x 1.

Remember your hierarchy. Chemotherapy always comes first then theraputic then hydration.

With this case the Taxol would provide the use for the initial code of 96413.

Hope this helps.
 
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96366 is not an initial code (96365 is the initial code in this code section).

You could bill 96366 on the same date of service as chemotherapy is there is a NON-CHEMO DRUG given over at least 1 hour 31 minutes (ie you are billing for 2 hours of administration time).

Example:
5FU given by push (J9190 and 96409 <-- initial code)
Leucovorin given over 2 hours (J0640 and 96367 and 96366)

The 96366 is the non-chemo equivalent of the 96415. It is billable beyond 1 hour and 30 minutes of administration time.

Hope this helps!

Alanna
 
96366 is not an initial code (96365 is the initial code in this code section).

You could bill 96366 on the same date of service as chemotherapy if there is a NON-CHEMO DRUG given over at least 1 hour 31 minutes (ie you are billing for 2 hours of administration time).

Example:
5FU given by push (J9190 and 96409 <-- initial code)
Leucovorin given over 2 hours (J0640 and 96367 and 96366)

The 96366 is the non-chemo equivalent of the 96415. It is billable beyond 1 hour and 30 minutes of administration time.

Hope this helps!

Alanna
 
In the first example, if the Zofran was given over 1 hour and 5 minutes, would 96366 be the appropriate code?

Taxol for 1 hour and Zofran for 1 hour and 5 minutes would be coded as (96413 x1 and 96366 x1)
 
No, 96366 would not be used for zofran given over 1 hour 5 minutes. The correct coding for the administration of the zofran would be 96367 x1.

If the zofran was given over 1 hour 35 minutes (more than 31 minutes into the next hour), then the administration for the zofran would be billed as 96367 x1 (1st hour) and 96366 x1 (2nd hour or 35 minutes) in addition to the 96413 for the Taxol.

The 96366 will always be billed with either 96365 or 96367 and is only billable if the administration for any single (non-chemo) drug is given for 1 hour and 31 minutes or longer. It is not billable for the first hour of administration of a drug.

I hope this helps. These codes can be very confusing! :)

Alanna
 
Very confusing indeed! I found an example that contradicts the logic described above:

http://www.ndhima.org/resources/SRoehl+Mastering+Injections+and+Infusions+NDHIMA+0412.pdf

Per CPT Changes (2013): "For both physician or other qualified health care professional and facility reporting, only one initial service code (eg, 96365) should be reported unless the protocol or patient condition requires that two separate IV sites must be utilized."

96365 is defined as: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366 is defined as: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour

96367 is defined as: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour

Seems like if the provider were to bill 96413 and 96365 the documentation would need to describe the second site and medical necessity would need to be established. If a second site is not established, then it would not be appropriate to bill 96365.

Thanks for your expertise!
 
You are correct, only one initial code is allowed per encounter (unless there extenuating circumstances, for example, 2 IV sites were required). I apologize if my explanation wasn't clear.

Initial codes can be (one) of the following:
96365 (non chemo infusion)
96374 (non chemo push or infusion less than 15 minutes)
96409 (chemo push or infusion less than 15 minutes)
96413 (chemo infusion)

Maybe examples would be the best way to make the use of these codes clear.

Example of non-chemo infusion:
Ferrlicit (iron infusion) in office
benadryl given over 60 minutes
Ferrlicit given over 60 minutes
The infusion portion would be coded as:
96365 x1 and 96367 x1 (one hour for each drug. one initial code and one sequential code.)

Ferrlicit given in office with test dose
benadryl given over 60 minutes
Ferrlicit test dose given over 60 minutes
Ferrlicit remaining portion of dose given over 60 minutes
Infusion would be coded as
96365 x1, 96367 x1, 96366 x1 (total the time of admin for the Ferrlicit to 2 hours)

Does this help? I remember being so confused by all this when I was first learning it!

Alanna
 
I'm understaind CPT 96366 as it has to be billed in conjunction with CPT 96365 and/or 96367.

CPT 96365 can only be billed if the hierarchy rules apply.
CPT 96366 woud only be billed if the infusion lasted longer than 90 minutes. CPT 96366 should not be billed as the 1st hour for any medication, it is only for times that exceed 90 minute, corect?
 
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