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96415 with modifier 52

  1. #1
    Scranton, PA
    Default 96415 with modifier 52
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    Patient comes in to our outpatient hospital department for chemotherapy. Chemotherapy was ordered for 2 hours, however due to the patient's condition it was not able to run for the entire 2 hours. The chemotherapy drug ran for exactly 90 minutes. Our coding wants to code 96413 and 96415-52. The coder is siting CPT Assistant August 2004 Pages 11,12 Category: Coding Consultation Related Information as well as the note from 3M that has the question asking what the appropriate codes to report for chemo admin via IV infusion techcnique with a total duration time of 90 minutes. Both are stating to use the modifier 52 on the add-on code since it was only 30 minutes. However this does not seem correct. Any assistance and documentation of this issue would be greatly appreciated.

  2. #2
    We use 52 modifier on the drug itself with "adverse reaction to drug" or similar comment under Additional info to get reimbursed at a reduced rate for the drug that was mixed but not used and that cannot be returned. We bill for the documented time of the infusion. For example, if a patient had a reaction after 12 minutes, we would bill 96409 (even if it was supposed to be 3 hour infusion).
    With that said, it might be helpful to place a call to the payer and see what are their policies regarding scenarios like this. Our local Medicaid doesn't recognize 52 mod, so we submit claims with "adverse reaction to drug" comment/ no modifier/ and CPT code that reflects documented time of the infusion. Best regards.

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