96413 + 96365: Is This Pairing Right?

Published: 12th April 2011
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Authoritative coding resources sometimes address even those encounters you do not handle on a daily basis. Here are two scenarios to test your skills and see whether your responses match the official rules.

Question 1: How many 'initial' codes are too many?

First challenge: Staff administers a non-chemotherapy therapeutic drug through one IV infusion site, and then following oncologist orders based on protocol, administers chemotherapy intravenously through a second IV site. In this scenario should you report the chemotherapy admin or the non-chemotherapy admin as the initial code?

Answer: Challenge 1 presents a trick question. You should code initial codes for both the chemotherapy and non-chemotherapy infusions.

According to CPT guidelines, while 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.

Many payers point out that when you code two initial code because each calls for a separate access site, you should add modifier 59 (Distinct procedural service). As such you may be required to add modifier 59 to the secondary 'initial' code to indicate the separate IV sites for each infusion in this case. For instance, your claim may cover the following:

  • 96413 -- Chemotherapy administration, intravenous infusion technique; up to an hour, single or initial substance/drug

  • 96365-59 -- Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to an hour.

    Question 2: Does 96446 apply to this intraperitoneal case?

    Second challenge: Documentation shows your oncologist took part in an operative encounter that involved providing intraperitoneal heated chemotherapy. As such, should you go for 96446 (Chemotherapy administration into the peritoneal cavity through indwelling port or catheter) for the chemotherapy administration?

    Answer: Well, the answer is no. For intraoperative intraperitoneal heated chemotherapy (IPHC or HIPEC) that's a planned and integral part of the procedure, the most appropriate code is 96549 (Unlisted chemotherapy procedure), as per CPT Assistant (Dec. 2010).

    IPHC takes place near the end of a surgical session in which a surgeon does away with tumors from the abdominal cavity. The doctor allows a warm chemotherapy solution to sit in the abdominal cavity and then drain.

    But why 96549? According to CPT Assistant, IPHC doesn't have a specific CPT code, however since the hyperthermic chemotherapy solution administration adds time to the surgical and anesthesia time and needs physician/operating suite staff work above and beyond that of the surgical procedure," you may code it separately. As per CPT guidelines, you shouldn't select a CPT code that merely approximates the service provided. If no such specific code exists, then the service using the proper unlisted procedure or service code. As such 96549 is the most appropriate code.

    And why not 96446? The temporary nature of the intraperitoneal catheter used for IPHC is what tells you 96446 is not proper for IPHC. Code 96446 is meant to report intraperitoneal chemotherapy administered through a permanently placed intraperitoneal catheter.

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