Breaking Down Complexities in Chemotherapy Injection Coding

Chemotherapy is a crucial part of infusion services. With a wave of cancer diagnoses potentially coming as result of people postponing routine cancer screenings during the pandemic, it is important to review some of the coding surrounding these services. Injection coding is an integral part of chemotherapy services with its own set of nuances. Here, we take time to explore the rationale behind these codes for fostering future success.

Analyzing Injection Coding Fundamentals

The first key to understand is that anti-neoplastic agents that are administered by subcutaneous or intramuscular injection are classified as either one of two things falling into hormonal or non-hormonal categories. Therefore, proper classification of the drug is necessary in order to arrive at the correct CPT code selection. Note that subcutaneous and intramuscular injection are among the less common modes of administration for chemotherapy agents. The substance is given directly by SQ or IM injection, as opposed to an intravenous injection (IV push) that requires a commitment of time at the patient’s bedside.

Administration of an anti-neoplastic substance by injection (SQ or IM) is reported using 96401 or 96402 under the following two circumstances:

• when the scheduled visit is for treatment of a cancer-related diagnosis,
• or when administering anti-neoplastic agents for treatment of non-cancer diagnoses (for example, methotrexate administered to treat rheumatoid arthritis).

It is necessary to take the step to confirm the functional and chemical classification of the substance administered (hormonal or non-hormonal) to ensure that the correct CPT code is reported for the injection.

Codes:

What about coding for certain highly complex monoclonal antibodies or highly complex biologic response modifiers administered for cancer as well as non-cancer diagnoses? For these circumstances, the AMA coding guidelines indicate that it is appropriate for providers to assign CPT codes 964XX. However, on the basis of subsequent communication to MedLearn, it is unclear whether this instruction applies to all drugs within the two classifications or only those that are assigned to a HCPCS code in the J9XXX series for chemotherapy agents.

Know that prior to assigning code 96401 or 96402 for the administration of a non-chemotherapy agent, it is necessary to confirm that the payer—either Medicare or a private insurer—recognizes the AMA instruction for reporting the administration of monoclonal antibodies or biologic response modifiers represented by HCPCS codes other than the J9XXX series. However, the facility can be confident in reporting the administration codes from this series when the substance injected has a primary indication for cancer treatment.

It is important to note that it is more or less a universally accepted principle by all payers—Medicare as well as commercial insurers—that erythropoiesis-stimulating agents (ESAs) do not qualify as highly complex drugs, and therefore the injection should be billed with 96372 and not as a chemotherapy administration.

During the release of the 2022 CPT code set, two new Category III options were added for reporting of intradermal cancer immunotherapy. These codes 0708T and 0709T detail injections delivered into the dermis layer of the skin as opposed to the subcutaneous fat layer under the skin.

Understanding Secondary Intent

When it comes to assessing primary intent, the injection codes 96401 and 96402 do not affect the determination of primary or secondary intent of an encounter. So, can this group of codes be reported with a combination of other services? The answer is yes. This group of codes may be reported in combination with hydration therapy, IV drug administration, or chemotherapy administration without affecting the “initial” code to be selected for an encounter.

Brief Billing Tips

• On occasion, due to the dose requested, the substance must be administered in split portions at different sites. When a single preparation of the drug exceeds the volume that can be safely injected at a single site, the substance will be injected in two or three portions. The administration should be recognized as a single administration and billed as one unit.
• SQ and IM injections may be quantity billed. Bill each medically necessary, individually prepared injection separately, regardless of whether the subsequent injection is or is not for a new substance.
• While CPT code 96377 represents a drug administration service, staff is reminded to report this code when an on-body injector is applied during the chemotherapy visit.

These are not all the billing tips necessary to tackle correct coding for chemotherapy injection. Secure the accurate reimbursement you deserve while mastering more everyday challenges and find further coding and compliance insights by utilizing our Coding Essentials for Infusion & Injection Therapy Services.