HealthCare News

Chemotherapy/Therapeutic Infusion Administration – Professional

Issue: #398 DEC2017

Topic: Coding/Billing


The following guidelines apply to the use of the chemotherapy/therapeutic infusion administration codes for professional claims.

  1. CPT® specifically notes that code 96376 is for use by the facility only. This code should not be billed by the physician on the CMS-1500.
  2. This series of codes includes an “initial” service code. This is the code that best describes the key reason for the patient encounter. It does not reflect the order that the infusions or injections occur.
    1. If a patient is admitted for the primary purpose of chemotherapy, but receives other infusions prior to the chemotherapy, the chemotherapy “initial” code is the only “initial” code used.
    2. There is only one “initial” drug administration code per encounter. The only exception to this is if the protocol requires that two separate IV sites must be utilized, or if the patient comes back for a second encounter on the same date of service. These services would be identified with modifier 59. Medical documentation must justify the use of the modifier.
  3. The chemotherapy administration codes (96401-96549) are for use with the parenteral administration of non-radionuclide anti-neoplastic drugs; and to anti-neoplastic agents provided for treatment of noncancer diagnoses. They may also be used for substances such as certain monoclonal antibody agents and other biologic response modifiers. These highly complex substances require additional physician and staff monitoring due to the higher incidence and severity of adverse reactions. Only certain pharmaceuticals will be allowed to be used with the chemotherapy administration codes. These include J9000-J9999, J1745, J0894 or J3315. Chemotherapy administration codes are not used for intravenous immunoglobulin (IVIG). IVIG is billed under therapeutic/diagnostic infusions.
  4. In order to bill “each additional hour,” a minimum of 31 additional minutes of services must be provided. Time units are calculated based on how long the fluid is actually infusing into the patient. Time ends when the fluids have infused. Documentation within the medical record should substantiate start and stop times for the services. An infusion of 15 minutes or less should be reported using a “push” code.
  5. An intravenous or intra-arterial push is defined as:
    An injection administered by a health care professional who is continuously present to administer the injection and observe the patient
    OR
    An infusion of 15 minutes or less. An infusion of 15 minutes or less should be reported using a “push” code.
  6. An IV line that only provides hydration, and is considered an integral part of chemotherapy or drug administration, is not separately reportable. This service is included in chemotherapy or other therapeutic administration codes.
  7. Hydration codes are intended to report IV infusion of pre-packaged fluid and/or electrolytes, but should not be used to report infusion of drugs or other substances.
  8. Code 96367 (additional sequential infusion, up to 1 hour) is used to report the infusion of a second or subsequent drug after the initial drug. This must be a sequential infusion, not a concurrent infusion. 96367 is reported once per drug.
  9. Code 96368 identifies a concurrent infusion. It is an add-on code and must be listed separately in addition to the code for the primary procedure.
    1. A concurrent infusion is when multiple infusions are provided simultaneously through the same intravenous line.
    2. Multiple substances mixed in one bag are considered to be one infusion.
    3. The concurrent infusion code can only be billed once per day.
    4. This code should not be used for chemotherapy infusions – it is used to report therapeutic/diagnostic infusions only.
  10. Code 96523 identifies a port flush and should be used when a patient comes only to have their port flushed with saline. This code should not be reported if any other service related to the port (e.g., lab draw or other infusion) is performed that day and will be reimbursed when it is the only service provided.
  11. Services such as the use of local anesthesia, IV start, access to indwelling IV (a subcutaneous catheter or port), a flush at the conclusion of an infusion, standard tubing, syringes and supplies are included in the payment for the drug administration service. These services should not be billed separately.
  12. E&M code 99211 should not be separately reported when drug administration services are provided. These services are incorporated into the RVUs for the administration codes.

The following CPT® codes are available for services in the outpatient hospital setting. Codes in bold print identify initial services (“+” indicates add-on code).

Hydration Administration Codes

CodeDefinition
96360Intravenous infusion, hydration; initial, 31 minutes to 1 hour
+96361Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure)

Therapeutic, Prophylactic, and Diagnostic Injections and Infusions

CodeDefinition
96365Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
+96366Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)
+96367Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (list separately in addition to code for primary procedure)
+96368Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); concurrent infusion (list separately in addition to code for primary procedure)
96369Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump
set-up and establishment of subcutaneous infusion site(s)
+96370Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)
+96371Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment
of new subcutaneous infusion site(s)
(list separately in addition to code for
primary procedure)
96372Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
96373Therapeutic, prophylactic or diagnostic injection (specify substance or drug);
intra-arterial
96374Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial
substance/drug
+96375Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure)
+96376Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of
the same substance/drug provided in a facility (list separately in addition to code for primary procedure)

Cannot be billed on the CMS-1500.
96377

Application of on-body injector
(includes cannula insertion) for timed subcutaneous injection
96379

Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion

Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

CodeDefinition
96401Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
96402Chemotherapy administration, subcutaneous or Intramuscular; hormonal anti-neoplastic
96405Chemotherapy administration; intralesional, up to and including 7 lesions
96406Chemotherapy administration; intralesional, more than 7 lesions
96409Chemotherapy administration; intravenous, push technique, single or initial substance/drug
+96411Chemotherapy administration; intravenous, push technique, each additional substance/drug (list separately in addition to code for primary procedure)
96413Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
+96415Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for primary procedure)
96416Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
+96417Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)
96420Chemotherapy administration, intra-arterial; push technique
96422Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour
+96423Chemotherapy administration, intra-arterial; infusion technique, each additional hour (list separately in addition to code for primary procedure)
96425Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump
96440Chemotherapy administration into pleural cavity, requiring and including thoracentesis
96446Chemotherapy administration into the peritoneal cavity via indwelling port or catheter
96450Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture
96521Refilling and maintenance of portable pump
96522Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial)
96523Irrigation of implanted venous access device for drug-delivery systems
96542Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents
96549Unlisted chemotherapy procedure