Sections:

1. General Infusion Information

2. Chemotherapy Drugs, Monoclonal Antibodies, and Biological Response Modifiers

3. Unlisted Drug Code Use

1. General Infusion Information
   There are CPT codes for several different types of infusions and injections for drugs and biologicals. These include codes for chemotherapy infusions and injections, therapeutic, prophylactic and diagnostic infusions, and injections and hydration.
   
   The CPT Manual published by the American Medical Association (2008) describes chemotherapy drugs and biologicals infusions and injections as requiring “physician work and/or clinical staff monitoring well beyond that of therapeutic drug agents (90760-90779) because the incidence of severe adverse patient reactions are typically greater.” (p424) These codes are paid at a higher rate to reflect the greater physician work and other resources required to safely administer these substances.
   
   For the therapeutic, prophylactic and diagnostic infusions and injections codes (90760-90779), the CPT states that: “if performed to facilitate the infusion or injection, the following services are included and are not reported separately:
   

   • use of local anesthesia;

   • IV start;

   • access to indwelling IV, subcutaneous catheter or port;

   • flush at conclusion of infusion;

   • standard tubing, syringes, and supplies.” (p.383)

   
   The CPT defines hydration as “pre-packaged fluid and electrolytes… not the infusion of drugs or other substances.” “Typically, such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set up, infusion typically entails little patient risk and thus little monitoring.” (p.384)
   
   For additional information on these services, and the rules for billing the initial and subsequent hours, please consult the CPT manual.
   
   Documentation for Infusions
   Start and stop times must be evident in the documentation in order to bill units for hours infused. If no start or stop time or total hours infused can be determined from the documentation, the best course is to query the clinician. If, in the circumstance that NO times are evident, an IV push code may be appropriate for billing since no infusion is supported beyond 15 minutes. Upon medical review, these services may be denied for insufficient documentation if billed as hours of infusion.

    

   ---

2. Chemotherapy
   General Information

   • Chemotherapy drugs are defined by the HCPCS Level II as drugs occurring in the range of J9000 through J9999.

   • Drugs in this range are assumed to require the complex drug administration services and physician supervision requirements inherent in CPT codes 96401-96417. The use these codes depends upon the drug administered, not the patient’s diagnosis, since many anti-neoplastic medications are used for treatment of illnesses besides neoplasm.

   • In addition to non-radionuclide anti-neoplastic drugs, HCPCS Level II codes J9000-J9999 also include biologic response modifiers (BRMs), monoclonal antibodies (MAs), and hormonal anti-neoplastics (HANs), the administration of which may be billed with chemotherapy administration codes.

   Biological Response Modifiers

   • Due to the complexity of their administration, certain other drugs meet the requirements for billing as chemotherapy injection or infusion services. Additional BRMs outside the J9000-J9999 range that are appropriate to use with these codes are listed below.

    

   Biologic Response Modifiers
   J0215	Alefacept 0.5 mg
   J7516	Cyclosporin Parenteral 250 mg
   J7525	Tacrolimus 5 mg
   Q3025	Interferon beta 1-a 11 mcg IM

   
   The anti-anemia or anti-emetic drugs used in cancer care do not warrant use of the chemotherapy administration and injection codes. Neupogen, Neulasta, Darbepoetin, Aranesp, Epogen and other similar drugs are not considered biological response modifiers for the purpose of coding drug administration and infusions and should be billed with the appropriate therapeutic injection codes.
   
   Monoclonal Antibodies

   • Monoclonal antibodies are frequently identified with generic drug names ending in “mab,” such as rituximab (J9310), trastuzumab (J9355), bevacizumab (J3095), etc. All MAs are appropriate for use with the chemotherapy administration codes.

   
   Hormonal Anti-Neoplastic Drugs

   • Hormonal anti-neoplastic drugs that lay outside the J9000-J9999 HCPCS range that may utilize the chemotherapy infusion or injection codes are listed below.

    

   Hormonal Anti-neoplastics
   J0128	Aberelix 10 mg
   J0970	Estradiol valerate up to 40 mg
   J1000	Depo-estradiol cypionate up to 5 mg
   J1380	Estradiol valerate 10 mg
   J1390	Estradiol valerate 20 mg
   J1410	Estrogen conjugate 25 mg
   J1435	Estrone 1 mg
   J3315	Triptorelin pamoate 3.75 mg

   
   
   Note: the lists of drugs and biologicals in this article are subject to change as new drugs are reviewed and evaluated.

1. Unlisted Codes for Drugs and Biologicals (J3490, J3590, J9999, and C9399)
   Unlisted codes should only be applied when no other code adequately describes the service.
   
   Unlisted codes are commonly used when the:
   

   • drug/biological does not have a specific HCPCS code;

   • drug/biological is administered by a route other than stated in the code;

   • amount of drug or biological is less than the amount, or of a different concentration, than specified in the HCPCS descriptor.

   
   
   For example, a 25 mg injection of Demerol is administered from a 25 mg vial. There is currently no HCPCS code for a 25 mg vial of Demerol. It would be appropriate to use J3490 in this instance. The only HCPCS code available for Demerol is J2175; for a 100 mg vial. If a 25mg injection of Demerol is administered from a 100 mg vial, then J2175 should be used with waste reported and documented in the medical record.
    

   • Preparation or make up of the drug or biological is other than specified in the descriptor, such as when billing compounded drugs for an implantable pain pump, or re-packaged drugs.

   Unlisted codes J3490, J3590, and J9999 billed to the Part A fiscal intermediary or MAC under the hospital OPPS are paid at a lesser rate or are packaged into the payment for other services on the claim. For non-OPPS facilities such as critical access hospitals (CAHs) and dialysis facilities, the claim is suspended for these codes and drugs are priced according to the remarks on the claim.
   
   Facilities under the hospital OPPS may use code C9399, billed as one unit, when the drug is FDA approved, but does not have an assigned HCPCS or the assigned HCPCS is not yet effective. Claims with C9399 are suspended and the drug is manually priced according to the remarks on the claim.
   
   Unlisted codes J3490, J3590, and J9999 billed to the Part B carrier or MAC are priced manually. For billing these unlisted codes the claim must include in Item 19 of the CMS-1500 or electronic equivalent:
   

   • Unit of service (= 1);

   • Name of the drug;

   • Dose administered (mg, cc, etc.);

   • Amount wasted (if any);

   • Route; and

   • NDC number (National Drug Code Number).

Claims billed to the carrier with C9399 will be rejected.

References:
Current Procedural Terminology 2008, American Medical Association
CMS Publication 100-4, Claims Processing Manual, Chapter 12, Section 30.5
CMS Publication 100-2, Benefit Policy Manual, Chapter 15, Section 50