Tips for Coding Drug Administration Codes - 2006 Update

Effective for dates of service on and after January 1, 2006, drug administration codes G0345-G0363 (which were valid for services rendered in 2005) have been replaced by CPT codes 90760-90779 and 96401-96522 (refer to chart 2).

The 2006 drug administration codes are grouped into three categories:

1. hydration
2. therapeutic or diagnostic injections/infusions (other than hydration)
3. chemotherapy administration

Chemotherapy administration codes may be used for reporting the administration of parenterally administered non-radionuclide anti-neoplastic drugs, as well as chemotherapy drugs for treatment of non-cancer diagnoses, monoclonal antibodies, and biologic response modifiers.

The types of intravenous administrations are defined as:

1. initial infusions
2. initial push
3. intravenous infusion each additional hour, up to eight hours
4. intravenous push, each additional drug or substance
5. sequential infusion
6. concurrent infusion
7. intravenous initiation of prolonged chemotherapy infusion (more than eight hours) requiring the use of a portable or implantable pump

“Push” administration is defined as an intravenous administration of 15 minutes or less in duration, whether administered as a bolus via syringe, or by a slow infusion.

Under the 2005 and 2006 instructions, only oneinitial drug administration code may be billed per patient per day, regardless of the category of drug administered. The only exceptions are if the protocol under which the beneficiary is being treated requires two separate intravenous catheters for access, or if there are separate encounters on the same day. In these cases, a second initial administration code may be billed using a -59 modifier. The initial administration code selected should reflect the purpose of the treatment, regardless of the order in which the drugs were actually administered. Generally, this is assumed to be the chemotherapy drug administration.

Each additional drug administered intravenously should be billed using the appropriate code for a sequential intravenous administration (for the first hour each drug). This sequential code is the equivalent of an initial infusion but for a second or subsequent drug. A drug administration coded this way must be administered before or after the infusions of all other drugs, and may not be simultaneous with other infusions.

A concurrent infusion is one that is administered at the same time as another drug. The drug must be prepared in solution separately from all other drugs. However, it would be administered via piggy-back setup or a single multiple-port catheter. A concurrent infusion means that each drug has its own bag or delivery system. The administration of multiple drugs mixed in a single bag is considered a single infusion, and should be coded accordingly. This should be reported once per encounter.

An injection or infusion may be defined as subsequent or concurrent even if the initial administration code was for a different category of drug (e.g., chemotherapy vs. diagnostic/therapeutic).

The codes for each additional hour up to eight (8) hours may only be billed if the time required after the first hour (this first hour is coded as either the initial infusion or the subsequent infusion) exceeds 30 minutes. Otherwise, the additional time is not billable.

Intramuscular and subcutaneous injections may be billed per drug. If a drug is administered in divided doses, then the administration should still be billed as a single service. Multiple different drugs may be billed individually. There are two codes for the intramuscular/subcutaneous administration of chemotherapy drugs. CPT code 96401 is used to bill the administration of non-hormonal anti-neoplastic drugs, and code 96402 is used to bill the administration of hormonal anti-neoplastic drugs (e.g., goserelin). Therapeutic or diagnostic injections are coded as 90772. This code should be reported with modifier -59 when used on the same day as an infusion service.

The HCPCS code for the specific medication administered must be included on the same claim as its administration code. Chemotherapy administration services will be denied if an appropriate drug requiring the administration indicated is not billed on the same claim.

When coding claims, the intravenous administration codes should be viewed as either base codes or add-on codes. The base codes are those that can be billed by themselves, while the add-on codes can only be billed if a base code is billed on the same claim (see chart 1). The sequence of coding for these codes is schematically displayed in charts 3 and 4 for chemotherapy and non-chemotherapy drugs, respectively.

Because many patients receive more than one drug during a session, it may occur that more services than could be submitted on a single claim (6 on paper or 13 electronically) would be billed. Consequently, services may be billed on two or more separate claims. Since add-on services must be submitted on the same claim as a base service and since drugs must be submitted on the same claims as their administration, it is important that the services be entered onto claims so that codes are properly grouped. Failure to coordinate the entry of services on an individual claim could result in the inadvertent denial of services because of the computer processing algorithms.

For information related to billing services for the 2006 Oncology Demonstration Project, refer to the CMS Web site at: http://www.cms.hhs.gov/MLNMattersArticles/2006MMAN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=8&sortOrder=ascending&itemID=CMS060690 .

Important Coding Points to Remember

• Only one initial administration code can be billed on any one day (unless the protocol requires two separate IV catheters or there are separate encounters on the same day).
• An administration code requires at least one related qualifying drug on the same claim.
• Administration of a monoclonal antibody or biologic response modifier may be coded with chemotherapy administration codes (does not include EPO or antiemetics).
• A sequential infusion, sequential IV push, or each additional hour up to eight hours, code needs an initial infusion or push as a base code.
• If an Evaluation & Management (E&M) service is provided (must be a significant and separately identifiable service), it should be billed on a claim with an administration code. CPT code 99211 is not covered with drug administration codes.
• Sequential infusion codes (90767, 96417) for multiple drugs should be billed on one line for each of these two codes with an NOS indicating the number of additional sequential drugs of each type.
• Sequential IV-push codes (90775, 96411) for multiple drugs should be billed on one line for each of these two codes with an NOS indicating the number of additional sequential drugs of each type.
• Concurrent infusions require that the drugs administered be separately prepared and in separate bags, although infused through a common catheter or port. This may be billed only once per encounter.
• The injection (SC or IM) code for a therapeutic or diagnostic drug (90772) can be billed on a separate claim (follow NOS instruction for multiple injections per above). The drug(s) being administered by this route must be reported on the same claim as the administration. It is necessary to use a -59 modifier when billing on the same day as an infusion.
• The injection (SC or IM) code for chemotherapy drugs (96401 or 96402) can be billed on a separate claim (follow NOS instruction for multiple injections per above). The drug(s) being administered by this route must be reported on the same claim as the administration.
• Venipuncture (36415), lab tests, and other tests can be billed on a separate claim from the chemo administration.

Chart 1
(Any add-on code may be billed with each base code)

Chart 2
Effective Dates for HCPCS Codes

Chart 3
Intravenous Drug Administration - Chemotherapy

1 Concurrent infusions are administered simultaneously with another drug. They must be prepared separately and in another bag, although can be infused through a “Y” connector or piggyback. They are not reimbursed based on duration of the infusion.

2 Can only bill one of these if administered simultaneously. Hydration can be reimbursed only if given before or after different initial infusion or chemotherapy.

Chart 4
Intravenous Drug Administration - Nonchemotherapy

1 Concurrent infusions are administered simultaneously with another drug. They must be prepared separately and in another bag, although can be infused through a “Y” connector or piggyback. They are not reimbursed based on duration of the infusion.

2 Can only bill one of these if administered simultaneously. Hydration can be reimbursed only if given before or after different initial infusion.

Chart 5
Drugs Billed Using Chemotherapy Administration Codes

© All current procedural terminology (CPT) codes and descriptors copyrighted by the American Medical Association.