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ASCO staff has received questions regarding the appropriate reporting of prolonged chemotherapy requiring the use of a pump. An article that appeared previously in Journal of Oncology Practice1 focused on the coverage and coding of infusion pumps. This article concentrates on the appropriate reporting of prolonged chemotherapy and provides the specific codes used in conjunction with this service. In addition, this article discusses portable and implantable infusion pumps used in prolonged infusions. It does not mention disposable pumps, because the Medicare program generally does not cover disposable pumps.
Certain chemotherapy regimens require that a chemotherapy drug be infused for a period of 8 hours or longer. In these regimens, it is common for the drug(s) to be administered through a portable or implantable pump and for the patient to leave the office after the pump is set up. Sometimes, the prolonged infusion requires the patient to return to the office or facility the next day to have the pump refilled so the infusion can continue. The Current Procedural Terminology (CPT) codes that describe the services related to prolonged chemotherapy infusions requiring portable infusion pumps are as follows:
The Healthcare Common Procedure Coding System (HCPCS) codes that identify the pumps used in prolonged infusions and the related equipment and/or supplies are as follows:
These HCPCS codes are recognized as durable medical equipment and/or supplies through which payment may be made through the Centers for Medicare & Medicaid Services and private payers. Although supplies are generally not covered by the Medicare program, durable medical equipment and associated supplies might be covered. Providers should verify coverage with their individual Medicare contractors and private payers.
Chemotherapy infusions that last less than 8 hours should be reported using the CPT codes for nonpump infusions such as 96413, 96415, and 96417. If a chemotherapy infusion should last longer than 8 hours but does not require the use of a pump, codes 96413, 96415, and 96417 should still be used to report the infusion. Only those chemotherapy infusions that last longer than 8 hours and require the use of a portable or implantable pump should be coded with the prolonged chemotherapy infusion codes: 96416 (for intravenous) and 96425 (for intra-arterial).
Prolonged infusion regimens using portable or implantable pumps require the filling of the pump or pump cassette with a particular drug or a mixture of drugs. When the patient presents for the set-up/activation of the pump and the initial filling of the pump or pump cassette, the appropriate chemotherapy administration code for the pump infusion should be reported (code 96416 and 96425, respectively). Prolonged infusions for 24 hours or longer may require that the pump or pump cassette be refilled. CPT code 96521 (for a portable pump) or 96522 (for an implantable pump) should be reported when the patient must come into the office to have the pump or pump cassette refilled.
It is important to note that the refilling of a pump should not be billed on the same day as the service for the activation and initial filling of the pump. These are two entirely separate procedures, and the initiation of the pump and the refilling of a pump should typically occur during two separate patient encounters on different days. For example, 96416 is reported on the day the pump is set up and initiated for the patient, and 96521 is reported for each subsequent day the pump needs to be refilled. When the treatment cycle or regimen begins again, code 96416 is reported for the initiation of the pump. The appropriate pump codes can also be reported to Medicare when prolonged services are being billed; however, the coverage of these items and the supplies should be verified by each individual Medicare contractor.
Physicians typically have an IV infusion pump in the office that regulates the speed or flow of infusions being provided in the office setting. These IV pumps are electric pumps that are mounted on a traditional IV pole and do not leave the office. It is inappropriate to bill separately for these pumps, because they are considered to be supplies and, therefore, are recognized and accounted for in the practice expenses for the drug administration codes.
HCPCS code E0781 represents an ambulatory infusion pump that is considered durable medical equipment. The ambulatory pumps are typically battery operated and smaller than the in-office infusion pumps. These are the pumps patients use for prolonged infusions when the patient must leave the office with the pump to continue the infusion for an extended period of time and return with it to have it refilled or disconnected.
In July 2010, the Centers for Medicare & Medicaid Services will publish a National Correct Coding Initiative edit that will restrict the reporting of E0781 with the drug administration codes that do not represent prolonged infusions.