This bulletin explains our chemotherapy drugs and physician administration policy as it relates to cancer treatments.
Do not use this policy to determine benefits for chemotherapy drugs and administration when you render treatment for an illness other than cancer.
Chemotherapy treatment used for the treatment of cancer is comprised of two components:
Administration includes the injection of the drug by the physician, subsequent medical visits rendered with administration services (e.g., subsequent office visit, subsequent hospital visit, follow-up consultation), the monitoring of the patient during administration, line maintenance supplies [including, but not limited to, low-cost diluents, low-cost additives (e.g., vitamins, Methoprednisone, insulin, heparin), syringes, IV solution, IV set, pump]. File office chemotherapy administration services using CPT procedure codes 96400 through 96549. If a physician has a face-to-face visit prior to the administration of chemotherapy level 3 or higher, the office visit may be allowed (99213-99215). Bill chemotherapy treatment during hospital care using the appropriate inpatient or outpatient evaluation and management codes.
If hydration is done during the same visit, and not done concurrently with the administration of chemotherapy, physicians may bill for "each additional hour.” If the office visit is for the purpose of line maintenance or flushing the line and there is no other chemotherapy administration, the provider should file the appropriate level of office visit.
Chemotherapy drugs can be taken orally or injected. Members should purchase oral medications from a pharmacy and file claims for them the same way as other prescription drugs. If a physician files the claim, the drug should be processed under the prescription drug program. When chemotherapy is injected, the patient can get the chemotherapy drugs from the physician at the time of administration, or the patient can purchase the drugs from a pharmacy and provide them for the physician to administer.
A physician who provides the injectable chemotherapy drugs and administers the chemotherapy treatment can receive benefits for both services. When the patient supplies the chemotherapy drugs, the physician can receive benefits for the administration only. Benefits for the chemotherapy drug charges are paid to the subscriber or pharmacy. When the physician provides the chemotherapy drugs for injection, he should report the charges using CPT codes J9000 through J9999, or the appropriate HIPAA drug code.