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29.2.11 Chemotherapy
Chemotherapy services are a benefit of the CSHCN Services Program when they are personally provided by a physician or under the supervision of a physician.
Note: Authorization is not required for administration of chemotherapy.
Physicians billing for chemotherapy administration may be reimbursed by using the appropriate procedure codes shown in the following table:
For the first 15 minutes through the first hour of chemotherapy infusion, procedure code 96409 or 96413 must be used for a single or initial chemotherapeutic medication. Procedure code 96411 must be used for each additional chemotherapeutic medication given and must be billed with procedure code 96409 or 96413.
Procedure code 96415 must be used for each additional hour beyond the initial hour and must be used in conjunction with procedure code 96413.
Procedure code 96417 must be used for each subsequent infusion up to 1 hour and must be used in conjunction with procedure code 96413. Procedure code 96415 must be used for each additional hour.
Procedure codes 96416 and 96425 must be used when initiating an infusion that will take more than 8 hours and requires using an implanted pump or a portable pump.
Procedure code 96422 must be used for the first hour of intra-arterial push administration. Procedure code 96423 must be used for each additional hour in conjunction with procedure code 96422.
The chemotherapy administration procedure codes listed above include charges for intravenous (IV) solutions (such as saline, dextrose and water, Ringer's solution, etc.), and IV equipment (administration sets, needles, extension tubing, etc.).
The chemotherapy administration procedure codes 96440, 96445, and 96450 include payment for the surgical procedure. Separate reimbursement for the surgical codes will not be allowed.
The appropriate E/M procedure code may be billed by a physician for a face-to-face visit with the client to review chemotherapy options.
Chemotherapeutic drugs and other injections given in the course of chemotherapy are reimbursed using the appropriate procedure code. The chemotherapeutic agents should be billed separately, including the name of the drug and actual amount administered for correct reimbursement. Procedure codes 96440, 96445, and 96450 include payment for the surgical procedure; separate reimbursement for the surgical code is not allowed. These procedure codes require the direct supervision of the physician.
Physicians providing a chemotherapy administration service as an inpatient service on the same day as an E/M service must bill using modifier 25, except for procedure code 99211. A different diagnosis is not required.
When a significant, separately identifiable E/M service is performed, the appropriate E/M code must be submitted with modifier 25 and the chemotherapy procedure code. A different diagnosis is not required for an E/M service provided on the same day. The provider must submit documentation of medical necessity upon appeal with modifier 25.
Modifier 25 must be used to describe circumstances in which an office visit was provided at the same time as other separately identifiable services. This modifier may be appended to the E/M code when the services are rendered. Both services must be documented as distinct and documentation must be maintained in the client's medical record and made available upon request by the CSHCN Services Program.
Chemotherapy planning program (procedure code 99213, 99214, or 99215) may be reimbursed.
Inpatient and outpatient hospitals must use revenue code 636 for reimbursement of the technical component. The appropriate chemotherapy procedure code must be listed on the claim.
Physicians are reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.
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