Applying CPT and HCPCS C-Codes and Rules for Drug...

Applying CPT and HCPCS C-Codes and Rules for Drug Administration Services to Clinical Scenarios

IMPORTANT – PLEASE READ

The information provided in this handout is informational only and should not be taken as an “official” answer of how to report codes and units for the services described in these clinical scenarios. Our audioconference speakers have provided this in an

attempt to help hospitals sort through a number of drug administration reporting issues, but each hospital must make its

own determination of how to report these services to Medicare and non-Medicare payers. If you are confused or disagree, we urge you to request guidance from your FI and CMS . We cannot provide any further information or explanations at this time. If you have further questions, please contact Nimitt Consulting at

jugna@nimitt.com to engage consulting services.

Answer for Clinical Example 1: Emergency Department Visit for a

Gastric Ulcer Patient

ED Visit Example

Service Time Explanation 2006 Codes 2006 CodesIVP 14:00 Protonix 90774 x 1 C8952 x 1

IVP 14:10 Demoral 90775 x 1 C8952 x 1

IVP 14:15 Ativan 90775 x 1 C8952 x 1

ED Visit ED Level III 99283 x 1 99283 x 1

2006 CPT Codes for non-

Medicare use

2006 HCPCS C-codes for

Medicare Use

Page 1

Answer for Clinical Example 2: Emergency Department and Observation Visit for a

Gastric Ulcer Patient

Service Time Explanation 2006 Codes 2006 CodesIVP 14:00 Protonix 90774 x 1 C8952 x 1

IVP 14:10 Demoral 90775 x 1 C8952 x 1

IVP 14:15 Ativan 90775 x 1 C8952 x 1

ED Visit ED Level III 99283 x 1 99283 x 1

Observation14:30 - 16:30 Admit to Obs 99235 x 2 G0378 x 2

Infusion started in Observation

14:30 - 16:30

Therapeutic Infusion

90767 x 1 90766 x 1

C8950 x 1 C8951 x 1

IVP 16:30 Dilaudid 90775 x 1 C8952 x 1

2006 HCPCS C-codes for

Medicare Use

ED and Observation Example

2006 CPT Codes for non-Medicare use

Page 2

Answer for Clinical Example 3:Multiple Push Injections of the Same Drug

Chemo Regimen

Service Time Explanation2005 CPT

Codes 2006 CPT Codes2006 C-Codes

IVP 1000-1005 Lasix 90784 x 1 90774 x 1 C8952 x 1*

IVP 1110-1115 Lasix 90784 x 1

IVP 1300-1305 Lasix 90784 x 1

IVP 1500-1505 Lasix 90784 x 1

2005 Hospital

Reporting

2006 CPT Codes for non-

Medicare use

2006 HCPCS C-Codes for Medicare

Use

Answer for Clinical Example 4: Concept of Concurrent Drug and CMS

Administration as Presented at the CPT Symposium in Chicago

Service Time Explanation

2006 CPT Codes for non-

Medicare use2006 C-Codes for

Medicare UseIVPB 1000-1100 Antibiotic 1 90765 x 1 C8950 x1

IVPB 1000-1100 Antibiotic 290768 x 1

No Medicare C-code available to report concurrent infusion

IVP 1115-1125 Phenrgan 90775 x 1 C8952 x 1

This is the answer presented by physicians at the CPT meeting in Chicago. We believe that there is no way to report the second antibiotic infusion on the Medicare side given that there is no code available and also because both infusions are of the same type. If the concurrent infusion was of a different type (i.e., a chemotherapy drug infusion), then we believe guidance from Transmittal 785 would allow us to report both the antibiotic and the chemo infusion. Page 4

Answer for Clinical Example 5: Two Chemotherapy Push Drugs with a

Non-Chemotherapy Drug

Service Time Explanation 2006 Codes 2006 codesIVP 9:00 PS-341 (chemo) 96409 x 1 C8953 x 1

IVP 10:02 5FU (chemo) 96411 x 1 C8953 x 1

IVP 9:30Leucovorin (non-chemo)

90775 x 1 C8952 x 1

Two Different Chemo Drugs Given IVP and Non-Chemo by IVP

2006 CPT Codes Non-Medicare

Use

2006 CPT and HCPCS C-codes

for Medicare Use

Page 5

Answer to Clinical Example 6: Chemotherapy Infusion with Anti-Emetics

Chemo Regimen

Service Time Explanation 2006 Codes 2006 Codes

IVP 10:00 - 10:10Decadron/Aloxi (non-chemo)

90775 x 1C8952 x 1

IVP 10:10 - 10:20 Reglan (non-chemo) 90775 x 1 C8952 x 1

IV infusion 12:20 - 14:20 Cisplatin (chemo)

96413 x 1 96415 x 1

C8954 x 1 C8955 x 1

2006 HCPCS C-codes for Medicare

Use

2006 CPT Codes for

Non-Medicare use

Page 6

Answer to Clinical Example 7: Chemotherapy Infusion with Anti-Emetics, Pre-and-

Post Hydration, and Additional Meds

Chemo Regimen

Service Time Explanation 2006 Codes 2006 Codes

IVP 10:00 - 10:10Decadron/Aloxi (non-chemo)

90775 x 1C8952 x 1

IVP 10:10 - 10:20 Reglan (non-chemo) 90775 x 1 C8952 x 1

IV infusion 10:20 - 12:20 Hydration90761 x 2 C8950 x 1

C8951 x 1

IV infusion 12:20 - 14:20 Cisplatin (chemo)96413 x 1 96415 x 1

C8954 x 1 C8955 x 1

IVP 14:20 - 14:55 Mannitol (non-chemo) 90775 x 1 C8952 x 1

IV infusion 14:55 - 16:55 Hydration 90761 x 2 C8951 x 2

IV infusion 16:55 - 17:55 Etoposide (chemo) 96417 x 1 C8955 x 1

IVP 17:55 - 18:05 Bleomyocin (chemo) 96411 x 1 C8953 x 1

2006 CPT Codes for non-Medicare use

2006 C-codes for Medicare

Use

Page 7

Answer to Clinical Example 8: Concept of Sequential Drug Administration as Presented at the CPT Symposium in Chicago

Chemo Regimen

Service Time Explanation2006 CPT

Codes 2006 C-CodesIVP 9:00-9:20 Ativan (non-chemo) 90775 x 1 C8952 x 1

IVPB 9:25-9:45 Decadron, Zofran, Benadryl (non-chemo)

90767 x 1 C8950 x 1

IV Infusion 9:45-10:45 Paraplatin (chemo) 96413 x 1 C8954 x 1

IV Infusion 10:45-11:15 Cytoxan (chemo) 96417 x 1 N/A

2006 CPT Codes for non-Medicare use

2006 HCPCS C-Codes for

Medicare Use

Note: There is no sequential chemotherapy infusion C-code available to report to Medicare. Also, the total time of the Paraplatin and Cytoxan does not meet the time requirement to bill any additional hours using the C8955 add-on code. Page 8

Service Time Explanation 2006 CPT Codes 2006 codes

IVP 13:15 (15 min) Zofran (non-chemo) 90775 x 1 C8952 x 1

90761 x 1 C8950 X 1

IVP 13:25 - 13:55 Adriamycin (chemo) 96411 x 1 C8953 x 1

IV infusion 14:00 - 15:30 Cytoxan (chemo) 96413 x 1 C8954 x 1

IV infusion 15:30 - 16:30 Taxotere (chemo) 96417 x 1 C8955 x 1

Codes/units if overlapping time for Cytoxan and Taxotere is deducted (hydration then = 45 minutes)

2006 HCPCS C-codes for

Medicare Use

IV infusion 13:15 - 16:45 Hydration90761 x 3 OR see below

C8950 x 1 C8951 x 2 or see below

Chemo Regimen w/ hydration hour overlapping with Chemo Infusion

2006 CPT Codes for non-Medicare use

Answer for Clinical Example 9: Chemotherapy Infusion and Hydration with Overlapping Time

Since the hydration runs throughout the course of the chemotherapy infusion, many hospitals are only reporting the non-overlapping hydration time and not the overlapping time (i.e., not the full duration of the hydration if it overlaps). Please request clarification from your FI and/or CMS. Page 9

Answer to Clinical Example # 10: Concept of Concurrent Infusions Under CPT

Codes vs. Medicare C-Codes

Service Time Explanation 2006 CPT Codes 2006 Codes

Chemotherapy drug injection 12:10 Fluorouracil given by the hospital as an IVP

96411 x 1 C8953 x 1

96413 x 1 96415 x 1

C8954 x 1 C8955 x 1

90768 x 1 C8950 x 1 C8951 x 1

SAMPLE FOLFOX REGIMEN

Non-chemotherapy drug infusion

10:00 to 12:00

The non-chemo drug Leucovorin is infused concurrently with the chemo drug Oxaliplatin through "Y" tubing. Order reads: Leucovorin 200mg/m2 IVPB run in 2 hrs.mg/m2 IVPB Run in 2 hrs.

2006 CPT Codes for non-Medicare

use

2006 HCPCS C-codes for

Medicare Use

Chemotherapy drug infusion

10:00 to 12:00

The drug Oxaliplatin is infused concurrently with the non-chemo Leucovorin drug through "Y" tubing. Oxaliplatin is compatible with Leucovorin, but not the second chemo drug Fluorouracil. Order reads: Oxaliplatin 85mg/m2 IVPB Run in 2 hrs.

There is no concurrent infusion C-code for Medicare. However, in this example, two different types of services are running concurrently (chemo and non-chemo). We believe Transmittal 785 allows for both of these services to be reported. The concept of “concurrent” is not well-defined, therefore hospitals should request clarification from their FI and/or CMS to determine how they will report this. We have requested official guidance but have not received a response as of Feb 3, 2006. Page 10