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Coding Q&A: Chemotherapy

Coding ToolsChemotherapyDiagnosis CodesE&MGlobal PeriodProcedures
Mar 15, 2021

Disclaimer: Answers to incoming questions are provided by the members of the Society of Gynecologic Oncology (SGO) Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

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What is the best diagnosis code to use for patients that are seen in the office, by their physician, prior to receiving chemotherapy at the hospital outpatient center? Is it correct to use Z51.11 with their E/M code when seen in the office?

The ICD-10 code for an evaluation prior to chemotherapy is Z01.818 (encounter for examinations prior to antineoplastic chemotherapy). Z51.11 is attached to the billing for the administration of chemotherapy so would not be used by the provider when the patient is going to a hospital-owned infusion center.


How do I bill for an office visit on the day of chemotherapy? What if the patient is still in the global period after surgery?

Office visits on the day of chemo should be reported using the appropriate E/M code (usually 99214-99215) with modifier -24 if during the global period. To indicate the reason for the visit use code Z01.818 (encounter for other preprocedural examination including encounter for examinations prior to antineoplastic chemotherapy), as well as codes for the primary cancer and sites of metastatic disease. If you are also going to be reporting the chemotherapy administration you can add Z51.11 (encounter for chemotherapy) and modifier -25 (E/M visit on day of procedure – the chemo administration is the procedure).


Can a gyn oncologist bill for chemotherapy counseling if that counseling falls within the global period following a surgical procedure?

Yes. Use the relevant E/M code with the 24 modifier for distinct E/M service during the global period. Also, you must use an ICD-10 code for counseling, such as Z71.89 (other specific counseling).


How do you bill for intraperitoneal (IP) chemotherapy?

96446 refers to chemotherapy administration into the peritoneal cavity via indwelling port or catheter. It is not time based. This single code covers all infusions into the peritoneal cavity for that day and does not include peritoneocentesis.


What ICD code do you use for laboratory testing done on a day prior to chemotherapy administration?

You should always report the ICD code that most accurately reflects the reason for the service being provided. In your example, that would be the most specific code for the disease or the presenting sign or symptom. For example, if the patient has a neutropenia, D70.1 would be reported followed by the cancer diagnosis. In the absence of a sign or symptom, then the cancer diagnosis should be primary.


What code should be used to bill a port flush by a nurse in the absence of any other service?

If the patient is seen only for a port flush, code 96523 should be used. If you use a de-clotting or thrombolytic agent, you should use code 36550. Also remember to use the J-code for the specific thrombolytic agent used. The diagnosis code should be the patient’s primary cancer and Z45.2 (encounter for adjustment and management of vascular access device).


When administering chemotherapy in an office setting, what are the requirements for the presence of the billing physician?

The billing provider must be “in the suite” as per Medicare rules. The interpretation of “in the suite” can vary, but should generally mean under the same roof and immediately available if needed. For example, the provider could be seeing patients in the same office suite where chemo is being administered, but could not be performing surgery in one part of an outpatient facility while supervising chemo in another part of the facility.


Is it sufficient for a Physician Assistant to be onsite in a clinic during a chemo infusion, or must a physician be physically onsite?

Non-physician providers can supervise chemo administration if allowed under state law and the insurance carrier rules for supervision. Rules may differ for NP’s and PA’s.


The physicians are currently on the hospital floor when the chemo is being administered by the nursing staff at the hospital and want to start billing for chemo administration. I was asked to look into billing and I have not been able to find anything that would allow us to bill at a hospital if the nursing staff is employed by a different employer than the providers. Can you please clarify under what conditions providers can bill for chemo in a hospital setting?

Chemo administration codes require that the staff are your employees and are giving the chemo in your facility. If the doctor sees the patient at the hospital on the day of the chemo, they could bill the appropriate E&M code but could not bill for the administration (i.e., 96365-96379 or 96401-96549). Chemotherapy administration codes reimburse primarily for the overhead/personnel costs of the infusion center. You can only bill for chemotherapy administration if you own the facility. If it is a hospital–based infusion center, you cannot collect for chemo administration. However, the amount of physician work associated with most chemo admin codes is only about 0.5 RVUs. You can charge for E&M codes if they are separately identifiable services. You then must document what was done and show medical justification for the visit. It should not be duplicative of clinic visits.


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