|
36.4.5.2 Chemotherapy
Chemotherapy infusion procedure codes listed in the following table are comprehensive codes that include all supplies, catheters, and solutions necessary to safely administer the necessary chemotherapeutic agents either by or under the supervision of the physician, but do not include the provision of the chemotherapeutic agents:
Chemotherapeutic infusion procedure codes are comprehensive codes that include all supplies, catheters, and solutions necessary to safely administer the necessary chemotherapeutic agents under the physician's direct supervision, but do not include the provision of chemotherapeutic agents. These procedure codes also include the appropriate invasive surgical procedure. As a result, a thoracentesis billed with 1-96440 is denied as part of 1-96440; a paracentesis billed with 1-96445 is denied as part of 1-96445; and a lumbar puncture billed with 1-96450 is denied as part of 1-96450.
These procedure codes (1-96440, 1-96445, and 1-96450) may be considered for reimbursement in addition to E/M codes billed on the same day, regardless of the POS billed.
Chemotherapeutic drugs and other injections given in the course of chemotherapy may be billed separately and considered for reimbursement using the appropriate procedure code(s).
Chemotherapeutic procedure codes may be considered for reimbursement in addition to E/M codes provided on the same day if the services occur in a sequential manner in POS 1, 2, or 5 for the following:
If the patient is hospitalized (POS 3), the physician should use the appropriate E/M codes. These chemotherapeutic procedure codes are denied as part of the daily hospital management codes in POS 3. If chemotherapy administration is the only service billed in POS 3, it is reimbursed.
Chemotherapy planning may be considered for reimbursement as a physician service.
When a chemotherapy planning program is billed by the same provider on the same date of service with office visits, consultations, hospital visits, and emergency room visits, the chemotherapy planning is considered for reimbursement, and the visits are denied as part of the chemotherapy planning.
Factors considered for planning chemotherapy treatment include, but are not limited to:
• The type of cancer.
•Where the cancer is located in the body.
•Whether the cancer has spread.
•Where the cancer has spread (if it has).
•The age and general health of the client.
•The frequency of chemotherapy treatment, and how long the treatment lasts, depending on factors that include, but are not limited to:
•Type of cancer.
•Drugs used.
•How the cancer cells respond to the drugs.
•Any side effects from the drugs.
Procedure code 2-51720 is used for Treatment of bladder lesion.
Chemotherapy Procedure Codes
Procedure code 2-51720 should be used for intravesical instillation of anti carcinogenic agents into the bladder including retention time.
The following surgical procedures necessary to place catheters and reservoirs for continuous anti carcinogenic agents must use one of the following appropriate surgical procedure codes:
Note: Prior authorization is not required for procedure codes 2-62350, 2-62360, 2-62361, and 2-62362 when used as a means for chemotherapy administration.
Prolonged infusion of chemotherapeutic agents is considered for reimbursement when submitted with procedure codes 1-96413 and 1-96422.
Since physicians are allowed reimbursement for only "face to face" contact, the subsequent hours of infusion therapy are not considered for reimbursement separately. Procedure codes 1-96415, 1-96423, 1-96416, and 1-96425 are not benefits of the Texas Medicaid Program.
Chemotherapy administration by push technique (procedure codes 1-96409, 1-96411, and 1- 96420) and by infusion technique (procedure codes 1-96413, 1-96415, 1-96416, 1-96422, 1-96423, and 1-96425) are considered for reimbursement when submitted with the same date of service. Infusion technique submitted with procedure codes 1-96415, 1-96416, 1-96423, and 1-96425 is not a benefit.
Only one intravenous push administration (procedure code 1-96409) and only one intra-arterial push administration (procedure code 1-96420) is allowed per day, regardless of whether separate drugs are given.
Refer to: "Texas Medicaid Prior Authorization Request Form: Intrathecal Baclofen or Morphine Pump Sections I and II (2 Pages)" .
|
