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96416..Please help!

  1. Default 96416..Please help!
    Medical Coding Books
    We bill charges for a protocol pt on study drug as:

    J2469 (aloxi)
    J1100 (decadron)
    96416 (initiation of prolonged chemo infusion, requiring use of a pump)
    96375 -59 x2 (sequential iv push)

    I have been getting denials from Medicare and Horizon for 96375- due to qualifying code. We were considering the 96416 as the initial admin.

    We received payments before from other insurances.
    Is this right

  2. #2
    When we bill for a FOLFOX regimen, for example, 96416 with 59 modifier (for 5FU in a pump) is used in conjunction with 96413 (for Oxaliplatin). I would say, the denial is due to lack of an initial (don't have a CPT in front of me - if you look it up, I believe, you will find that the rationale as to why it can be used in conjunction with other initials). So, I would code 96374 + 96375 + 96416/59 for your study drug. Best regards
    Lioubov Petrova, CPC, CHONC, CEMC, CPMA

  3. #3
    I would agree with Ipetrova. Our MC carrier has been requesting we bill an initial admin when we bill the 96416. For years and years, the 96416 was considered an initial, but recently that's not the case. Go ahead and try the 96374, 96375-59, 96416. Good luck!

  4. Default
    I also agree with above. 96416 is not an initial code. Payable when used in conjuction with inital codes...bill out with a modifer 59 on 96416

  5. #5
    Augusta, GA
    Why would you not bill a 96413 as the initial? I have only used the 96416 for administration of J9190. The Oxiliplatin (J9263) has been billed with a 96413 and 96415 x2

  6. #6
    Nashville, TN
    agreed. 96416 is not an initial code.
    Len Hales, RN, BSN, CPC

  7. Default
    I just got a denial from a local insurance company for a 96365 used in conjunction with the 96416. As per the insurance company "96416 is initial code and the 96365 is inclusive". I am appealing this as the insurance company is wrong.

  8. #8
    Bettendorf, Iowa
    96416 is not a qualifying code for 96375 or 96367. You would bill 96374 with a 59 modifier + 96375. If they deny that I would appeal it along with a copy of the CPT manual. The 59 is not on the 96416 since that is the main procedure and the reimbursement rate is higher.
    Ruth Long CPC,CHONC

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