How to Bill and Code Chemotherapy Procedures Using CPT Codes

by | Last updated Dec 3, 2022 | Published on Nov 7, 2022 | Blog, HCPCS Coding, Medical Billing, Medical Coding | 0 comments

Chemotherapy Procedures
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Regarded as an aggressive form of chemical drug therapy, chemotherapy (often called chemo) uses powerful chemicals to destroy rapidly growing cells in the body. Generally, the therapeutic procedure is used to treat cancer – as cancer cells grow and divide faster than other cells in the human body. There are different types of chemotherapy which in most cases are used alone or in combination with other therapies to treat a wide variety of cancers. However, the use of combination therapy depends on several factors like -the stage and type of cancer, the location of the cancer cells, history of previous cancer treatments, the overall health condition of the patient and the personal treatment preferences of the patient. The procedure is generally considered a systemic treatment, which means it affects the entire body.

Even though the treatment procedure has been proven to effectively attack the growing cancer cells, it may cause serious side effects or complications that can severely impact the quality of life of people. Therefore, it is important to weigh these side effects against the risk of going untreated when deciding if chemotherapy is the right option for a patient. Oncologists or other physicians performing chemotherapy need to correctly document the procedures in the patients’ medical records. Outsourcing billing and coding tasks to a reliable radiology medical coding company can help simplify the documentation process.

Why Chemotherapy Is Performed -Risks and Side effects

Primarily, chemotherapy is performed to kill cancer cells in people with cancer. The human body is made of trillions of cells, which die off and multiply as part of the normal growth cycle. Cancer occurs when abnormal cells in the body multiply at a rapid and uncontrolled pace. In certain other cases, these cells grow into tumors or masses of tissue. Chemotherapy may be used in people with cancer to-

  • Reduce the total number of cancer cells in the body
  • Reduce the likelihood of cancer spreading
  • Trigger apoptosis (suicide of cancer cells)
  • Slow the progression of the disease
  • Shrink tumor size (before surgery)
  • Remove any remaining cancer cells and delay or prevent a recurrence (after surgery)
  • Kill the hidden cancer cells and prevent cell division
  • Reduce symptoms in the later stages (even if a cure is unlikely)

In certain other cases, chemotherapy drugs are useful in treating other conditions like -bone marrow disease and immune system disorders. As mentioned above, chemo procedure is designed to kill cells that divide rapidly; however, cells in body areas such as -hair, skin, blood and the lining of the intestinal tract can be adversely affected by the procedure. Side effects of chemotherapy drugs can be significant. Each drug has different side effects, and not every drug causes every side effect. Some of the common side effects include –

  • Weight loss
  • Vomiting and nausea
  • Mouth sores
  • Loss of appetite
  • Hair loss
  • Fever
  • Fatigue
  • Easy bruising and excessive bleeding
  • Dry mouth
  • Diarrhea
  • Pain from nerve damage
  • Infections
  • Skin changes

In fact, most of these side effects subside when the treatment is over. However, there may be a risk of long-lasting effects that may develop even years after treatment, depending on the type of chemotherapy used. These long-lasting effects can cause serious damage to the different body organs namely heart, lungs, kidneys, nerves and reproductive organs. Physicians may prescribe medications, dietary changes and other lifestyle habits that can help people manage these side effects in a better manner. In addition, there is also a chance of developing a second cancer as a result of chemotherapy. Therefore, before beginning treatment, patients need to talk to their physicians about the possible risks and what symptoms they should be aware of.

Types of Chemotherapy

Chemotherapy can be administered in several ways. Oncology specialists will recommend the best type of chemotherapy procedure based on the type, location and severity of the cancer. Some of the most common types of chemotherapy include –

  • Intravenous chemotherapy -Generally, administered into a vein, this type is usually performed in a hospital and involves medicine being given through a tube into a vein in the hand, arm or chest.
  • Adjuvant chemotherapy -Usually administered after surgery, this type helps to kill cancerous cells that may remain undetected and prevent recurrence of the cancer.
  • Neo-adjuvant chemotherapy -This therapy aims to shrink too large tumors to make it possible to remove them surgically.
  • Oral chemotherapy -Chemotherapy tablets, it usually involves taking a course of medicine at home, with regular check-ups in hospital.
  • Palliative chemotherapy -This type of chemo is typically administered for those cancers that have spread radically and are impossible to remove surgically. Physicians may use palliative chemotherapy to relieve symptoms, reduce the chances of complications, thereby slowing down the progress of the disease or stopping it temporarily.

Generally, patients may be treated with one type of chemotherapy medicine or a combination of different types. Patients need to attend several treatment sessions, which will typically be spread over the course of a few months.

How Is Chemotherapy Procedure Performed?

As chemotherapy is an important treatment modality for a serious condition, it is important to plan well in advance before beginning the treatment. Preparing for the procedure may depend on the type and dosage of drugs usage and the mode of administration. Before undergoing a chemo session, physicians will recommend a series of tests to analyze whether a patient’s body is fit enough to withstand the drug dosage and other complications of the treatment. These include -blood tests (to check the kidney, liver and heart functions) and dental checkups (to test the teeth for signs of infections). These tests can help guide physicians in deciding the type of chemotherapy to be used as part of the treatment. If any of these tests show any specific problem, physicians may postpone the treatment or select a different chemo drug and dosage that is safer for the patient.

Patients need to prepare well in advance before undergoing the first chemotherapy session and remain well-rested. They may be recommended to consume a light meal beforehand in case the chemotherapy medications cause nausea. Furthermore, patients need to take the help of a family member or friend to accompany them to and from their first chemo session. This is because the medications injected can make patients sleepy or cause other serious side effects. Chemotherapy drugs can be administered in different ways, including –

  • Infusions into an artery or vein (intravenously)
  • Injections into the muscle or under the skin or into the fluid around the spinal cord or brain
  • Oral pills, liquid or capsule form
  • Topically, onto the skin (as creams or gels)

Patients who are administered intravenous chemo (into vein or artery) may require a minor surgical procedure to have a thin catheter (called a central line or port) implanted into a vein to administer the drugs. The schedule of chemotherapy sessions will be decided by the oncologist depending on the type of drug administered, type and symptoms of cancer, and how well the body recovers after each treatment. The treatment schedules may vary and can be either continuous or it may alternate between periods of treatment and periods of rest to allow the patient to recover properly.

Medical Codes to Report Chemotherapy Procedures

Medical billing and coding for chemotherapy procedures can be complex as it involves several rules related to reporting the procedure correctly. Physicians administering the chemotherapy treatment musk have adequate knowledge about the CPT codes to bill correctly for the procedure.

CPT Codes

  • 96360-Intravenous infusion, hydration; initial, 31 minutes to 1 hour
  • 96361 -Intravenous infusion, hydration; each additional hour
  • 96365-Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
  • 96366 -Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour
  • 96367 -Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour
  • 96368 -Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion
  • 96369 -Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)
  • 96370 -Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour
  • 96371 -Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s)
  • 96372 -Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
  • 96373 -Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra arterial
  • 96374 -Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
  • 96375 -Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug
  • 96376 -Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility
  • 96377 -Application of on-body injector (includes cannula insertion) for timed subcutaneous injection
  • 96379 -Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion
  • 96401 -Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic
  • 96402 -Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic
  • 96405 -Chemotherapy administration; intralesional, up to and including 7 lesions
  • 96406 -Chemotherapy administration; intralesional, more than 7 lesions
  • 96409 -Chemotherapy administration; intravenous, push technique, single or initial substance/drug
  • 96411 -Chemotherapy administration; intravenous, push technique, each additional substance/drug
  • 96413 -Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
  • 96415 -Chemotherapy administration, intravenous infusion technique; each additional hour
  • 96416 -Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
  • 96417 -Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour
  • 96420 -Chemotherapy administration, intra-arterial; push technique
  • 96422 -Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour
  • 96423 -Chemotherapy administration, intra-arterial; infusion technique, each additional hour
  • 96425-Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump
  • 96440 -Chemotherapy administration into pleural cavity, requiring and including thoracentesis
  • 96446 -Chemotherapy administration into the peritoneal cavity via indwelling port or catheter
  • 96450 -Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture
  • 96521 -Refilling and maintenance of portable pump
  • 96522 -Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (e.g., intravenous, intra-arterial)
  • 96523 -Irrigation of implanted venous access device for drug delivery systems
  • 96542 -Chemotherapy injection, subarachnoid or intra-ventricular via subcutaneous reservoir, single or multiple agents
  • 96549 -Unlisted chemotherapy procedure

HCPCS Code

  • G0498 -Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/clinic setting using office/clinic pump/supplies, with continuation of the infusion in the community setting (e.g. home, domiciliary, rest home or assisted living) using a portable pump provided by the office/clinic, includes follow-up office/clinic visit at the conclusion of the infusion.

The final results of a chemotherapy treatment will largely depend on the type, stage, and location of the cancer and the overall health of the patient. An oncologist will analyze the progress of chemotherapy treatment on a regular basis to determine how well a patient is responding to treatment, and specific side effects occurring during the course of treatment -so that the treatment methodology can be adjusted accordingly.

Billing and coding require correct knowledge regarding appropriate codes and modifiers. Payer-specific medical billing is essential for correct and on-time reimbursement. With all the challenges involved, the support of a reliable medical billing company can prove valuable for physicians to correctly report chemotherapy procedures.

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