Coding is all about applying standardized code sets to situations that don’t always qualify as “standard.” The good news is that authoritative coding resources sometimes address even those encounters you don’t handle on a daily basis. Test your skills with these two scenarios and see whether your responses match the official rules.
Challenge 1: Staff administers a non-chemotherapy therapeutic drug via one IV infusion site, and then following oncologist orders based on protocol, administers chemotherapy intravenously via a second IV site. Should you report the chemotherapy admin or the non-chemotherapy admin as the initial code?
Solution 1: Challenge 1 presents a trick question. You should report initial codes for both the chemotherapy and non-chemotherapy infusions.
CPT guidelines state, “When administering multiple infusions, injections or combinations, only one ‘initial’ service code should be reported, unless protocol requires that two separate IV sites must be used,” notes Gwen Davis, CPC, associate with Washington-based Derry, Nolan, and Associates.
Citing this same rule, Tracy Helget, CPC, in the business office of Medical Associates of Manhattan in Kansas, notes, “The easiest way to think of this is, if we are making more than one stick to the patient, we bill more than one initial code.”
Many payers indicate that when you report two initial codes because each requires a separate access site, you should append modifier 59 (Distinct procedural service). So you may need to append modifier 59 to the secondary “initial” code to indicate the separate IV sites for each infusion in this case. For example, your claim may include the following:
- 96413 – Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
- 96365-59 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.
Challenge 2: Documentation indicates your oncologist participated in an operative encounter that involved providing intraperitoneal heated chemotherapy. Should you report 96446 (Chemotherapy administration into the peritoneal cavity via indwelling port or catheter) for the chemotherapy administration?
Solution 2: No. For intraoperative intraperitoneal heated chemotherapy (IPHC or HIPEC) that is a planned and integral part of the procedure, the most appropriate code is 96549 (Unlisted chemotherapy procedure), according to CPT Assistant (Dec. 2010).
IPHC takes place near the end of a surgical session in which a surgeon removes tumors from the abdominal cavity. The physician allows a warm chemotherapy solution to sit in the abdominal cavity and then drain.
Why 96549? CPT Assistant states that IPHC does not have a specific CPT code, but because “the hyperthermic chemotherapy solution administration adds time to the surgical and anesthesia time and requires physician/operating suite staff work above and beyond that of the surgical procedure,” you may report it separately. CPT guidelines instruct: “Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code.” So 96549 is the most appropriate code.
Why not 96446? The temporary nature of the intraperitoneal catheter used for IPHC is what tells you 96446 is not appropriate for IPHC. “Code 96446 is intended to report intraperitoneal chemotherapy administered through a permanently placed intraperitoneal catheter,” CPT Assistant states.
CPT Changes 2011: An Insider’s View explains that 96446 is appropriate for admin through an inatraperitoneal catheter placed at a separate setting. The catheter has a reservoir under the skin, and the staff may access it multiple times via a Huber needle. CPT Changes 2011 states the physician provides direct supervision, meaning he’s immediately available to manage any symptoms that arise.
Look for more coverage in Oncology Coding Alert, written by Deborah Dorton, CPC.