HealthCare News

Outpatient Chemotherapy/Therapeutic Infusion Administration – Institutional

Issue: #398 DEC2017

Topic: Coding/Billing


The following guidelines apply to the use of the outpatient chemotherapy/therapeutic infusion administration codes within the facility setting.

  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. This code may not be reported with less than a 30-minute interval for sequential intravenous push administration of the same drug.
  2. According to CPT®, when these codes are reported by the facility, there are certain instructions that apply. The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic and diagnostic services, which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.
  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 non-cancer 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. A separate amount will be reimbursed for “each additional hour” as services will not be reimbursed on a bundled “per encounter” rate. It remains important to correctly identify the units for these services.
  5. 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.
  6. There is only one “initial” drug administration code per encounter. The only exceptions to this are 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.
  7. An intravenous or intra-arterial push is defined as:
    a. An injection administered by a health care professional who is continuously present to administer the injection and observe the patient
    OR
    b. An infusion of 15 minutes or less. An infusion of 15 minutes or less should be reported using a “push” code.
  8. 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.
  9. Hydration codes are intended to report IV infusions of pre-packaged fluid and/or electrolytes, but should not be used to report infusion of drugs or other substances.
  10. 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.
  11. 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.
    5. The concurrent infusion code will not be reimbursed separately. It will be bundled into other services.
  12. 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.
  13. 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.
  14. All providers, including Critical Access Hospitals (CAHs), will use these codes to identify infusion services.
  15. If the same drug is being given in multiple pushes, only one unit can be billed. An additional IV push can be billed for each new substance/drug.
  16. These codes should not be submitted for infusions given during the course of an outpatient surgical procedure. IV infusions during surgery and recovery are considered part of the surgery and are included in the outpatient surgical roll-up.
  17. If a patient is hospitalized during the course of the outpatient chemotherapy, outpatient claims must be split so they do not overlap the inpatient stay.
  18. Due to the number of services provided during outpatient chemotherapy administration or other therapeutic infusions, claims tend to be lengthy. The adjudication process will be improved if shorter date spans are used when submitting these claims.
  19. Line-item service dates are required on these types of claims.

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

Hydration Administration Codes

CodeDefinitionUnits
96360Intravenous infusion, hydration; initial, 31 minutes to 1 hour1
+96361Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)Multiple

Therapeutic, Prophylactic, and Diagnostic Injections and Infusions

CodeDefinitionUnits
96365Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to
1 hour
1
+96366Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)Multiple
+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)Multiple
+96368Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); concurrent infusion (list separately in addition to code for primary procedure)Bundled into other payment
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)1
+96370Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)Multiple
+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)Multiple
96372Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscularMultiple
96373Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterialMultiple
96374Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug1
+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)
Multiple
+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.
Bundled into other payment
96377Application of on-body injector (includes cannula insertion) for timed subcutaneous injection1
96379Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusionMultiple

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

CodeDefinitionUnits
96401Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplasticMultiple
96402Chemotherapy administration, subcutaneous or Intramuscular; hormonal anti-neoplasticMultiple
96405Chemotherapy administration; intralesional, up to and including
7 lesions
Multiple
96406Chemotherapy administration; intralesional, more than 7 lesionsMultiple
96409Chemotherapy administration; intravenous, push technique, single or initial substance/drug1
+96411Chemotherapy administration; intravenous, push technique, each additional substance/drug (list separately in addition to code for primary procedure)Multiple
96413Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug1
+96415Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for
primary procedure)
Multiple
96416

Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump1
+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)Multiple
96420Chemotherapy administration, intra-arterial; push techniqueMultiple
96422Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour1
+96423Chemotherapy administration, intra-arterial; infusion technique, each additional hour (list separately in addition to code for primary procedure)Multiple
96425Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring
the use of a portable or
implantable pump
1
96440Chemotherapy administration into pleural cavity, requiring and including thoracentesisMultiple
96446Chemotherapy administration into the peritoneal cavity via indwelling port or catheterMultiple
96450
Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture
Multiple
96521Refilling and maintenance of portable pump1
96522Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial)1
96523Irrigation of implanted venous access device for drug-
delivery systems
1
96542Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agentsMultiple
96549Unlisted chemotherapy procedureMultiple
C8957Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring the use of portable or implantable pump1