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...
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