Chemotherapy Administration Coding Guidelines 2022

The Centers for Medicare & Medicaid Services (CMS) recently published revised coding guidelines for CPT codes 90000 – 99999. In this Blog, we shared CPT codes applicable for Chemotherapy Administration Coding and minor updates in guidelines. 

Chemotherapy Administration Coding Guidelines 2022

Reporting Initial Service Code

The CPT codes 96360, 96365, 96374, 96409, and 96413 describe ‘initial’ service codes. For a patient encounter, only 1 ‘initial’ service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites. To report 2 different ‘initial’ service codes, you can use appropriate modifiers.

Using Correct POS

CPT codes 96360-96379, 96401-96425, and 96521-96523 are reportable by providers/suppliers for services performed in physicians’ offices. These drug administration services shall not be reported by providers/suppliers for services provided in a facility setting such as a hospital outpatient department or emergency department. Drug administration services performed in an Ambulatory Surgical Center (ASC) related to a Medicare- approved ASC payable procedures are not separately reportable by providers/suppliers. Hospital outpatient facilities may separately report drug administration services when appropriate. The term ‘Physician’ in this article refers to M.D.s, D.O.s, and other practitioners who bill Medicare claims processing contractors for services payable on the MPFS (Medicare Physician Fee Schedule).

Billing CPT 99211

The drug and chemotherapy administration HCPCS/CPT codes 96360-96375, 96377 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 (E&M service, office or other outpatient visit, established patient, level I). Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility-based E&M CPT codes (e.g., 99202- 99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service. 

Since providers/suppliers shall not report drug administration services in a facility setting, a facility-based E&M CPT code (e.g., 99281- 99285) shall not be reported with a drug administration CPT code unless the drug administration service is performed at a separate patient encounter in a non-facility setting on the same date of service. In such situations, the E&M code should be reported with modifier 25. Under the OPPS (Outpatient Prospective Payment System), hospitals may report drug administration services and facility-based E&M codes (e.g., 99281-99285, G0463) if the E&M service is significant and separately identifiable. In these situations, modifier 25 should be appended to the E&M code.

Inappropriate Use of CPT 96523

Flushing or irrigation of an implanted vascular access port or device prior to or subsequent to the administration of chemotherapeutic or non-chemotherapeutic drugs is integral to the drug administration service and is not separately reportable. Under these circumstances, do not report CPT code 96523.

Billing ‘refilling & maintenance of an implantable pump/reservoir for systemic drug delivery’

CPT code 96522 describes the refilling and maintenance of an implantable pump or reservoir for systemic drug delivery. The pump or reservoir must be capable of programmed release of a drug at a prescribed rate. CPT code 96522 shall not be reported for accessing a nonprogrammable implantable intravenous device for the provision of infusion(s) or chemotherapy administration. 

CPT code 96522 (Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial) and CPT code 96521 (Refilling and maintenance of portable pump) shall not be reported with CPT code 96416 (Initiation of prolonged intravenous chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump) or CPT code 96425 (Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours) requiring the use of a portable or implantable pump). CPT codes 96416 and 96425 include the initial filling and maintenance of a portable or implantable pump. CPT codes 96521 and 96522 are used to report subsequent refilling of the pump.

CPT codes 96521 and 96522 shall not be reported for accessing or flushing an indwelling peripherally-placed intravenous catheter port (external to skin), subcutaneous port, or nonprogrammable subcutaneous pump. Accessing and flushing these devices is an inherent service facilitating these infusion(s) and is not reported separately.

Billing CPT Code 96368

A concurrent intravenous infusion of an antiemetic or other non-chemotherapeutic drug with intravenous infusion of chemotherapeutic agents may be reported separately as CPT code 96368 (Concurrent intravenous infusion). CPT code 96368 may be reported with a maximum of one unit of service per patient encounter regardless of the number of concurrently infused drugs or the length of time for the concurrent infusion(s). Hydration concurrent with chemotherapy is not separately reportable.

MedicalBillersandCoders (MBC) is a leading medical billing company providing complete revenue cycle solutions. CPT® is a registered trademark of the American Medical Association (AMA). We shared some of CPT codes and it’s guidelines for reference purpose only, for accurate use please refer to detailed code description. If you need assistance in Chemotherapy Administration Coding service, contact us at 888-357-3226