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24.3.8 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 by the physician or outpatient facility for chemotherapy administration when performed in the outpatient facility.
When chemotherapy is administered in a physician's office, the physician may be reimbursed by using the appropriate CPT codes shown in the following table:
These procedures are independent of the client's visit in any place of service (POS) except inpatient hospital. Chemotherapy administration is included in the initial or subsequent care contact in the inpatient hospital setting (POS 3). It cannot be paid as a separate service in that POS, unless it is the only service billed that day.
Chemotherapy procedure codes 1-96416 and 1-96425 are not a benefit of the CSHCN Services Program.
The chemotherapeutic agents must be billed separately, including the name of the drug and the actual amount administered, for correct reimbursement.
Chemotherapy administration procedure codes listed above include charges for intravenous (IV) solutions (such as saline, dextrose and water, Ringer's solution, etc.), IV equipment (administration sets, needles, extension tubing, etc.), time spent administering the drugs, and subsequent observation of the client.
Procedure codes 1-96440, 1-96445, and 1-96450 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.
Note: E/M services are payable in addition to procedure codes 1-96440, 1-96445, and 1-96450.
The prolonged infusion of chemotherapeutic agents has specific reimbursement limitations. Procedure codes 1-96413 and 1-96422 are limited to one per day. Subsequent hours should be billed with procedure codes 1-96415 and 1-96423 and are limited to two per day. Only two chemotherapy procedures are allowed on the same day.
Chemotherapeutic drugs and other injections given in the course of chemotherapy may be reimbursed using the appropriate HCPCS code.
Chemotherapy planning programs may be reimbursed. No other client contact procedure code is reimbursed on the same day.
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