Knowledge Base Article

In life, sometimes you win and sometimes you lose. The same goes for dealings with Medicare although most of us probably think we lose more than we win in this arena. But every now and then the providers come out to the good. At the beginning of last year, CPT code 96416 was the appropriate code to bill for prolonged chemotherapy infusions using a portable or implantable infusion pump. Last year, some Medicare Administrative Contractors (MACs) instructed to use an unlisted code for this service. Now there is a new code. Why have there been so many coding changes for this service and what is included in the current code?

The definition for CPT code 96416 is “Initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump” and it was at one time the appropriate code to bill for these prolonged infusions. In April, 2016, CMS released MLN Matters Article SE1609. The main point of this article seemed to be to emphasize that the pump used for these prolonged infusions should not be billed separately as a DME item. The article stated, “Medicare’s payment for the administration of the drug or biological billed to the MAC will also include payment for equipment used in furnishing the service. Equipment, such as an external infusion pump used to begin administration of the drug or biological that the patient takes home to complete the infusion, is not separately billable as durable medical equipment for a drug or biological paid under the section 1861(s)(2)(A) and (B) incident to benefit.”

The article went on to say that the MACs could direct use of a specific CPT or HCPCS code to be used to report the service, even a miscellaneous code “if there is no specified code that describes the drug administration service that also accounts for the cost of equipment that the patient takes home to complete the infusion that they later return to the physician or hospital.” Some MACs did instruct their providers to use the miscellaneous chemotherapy CPT code, CPT 96549. This caused great angst for providers because the Medicare OPPS unadjusted payment rate for 2016 for CPT 96549 was $30.87 as opposed to $280.27 for CPT 96416. The payment rate for the miscellaneous code failed to even cover the cost of providing the service.

Luckily for providers, this unfair payment situation was remedied with the creation of a new HCPCS code to describe the administration service and also account for the equipment cost. In the April 2017 OPPS Update, Medicare instructed the use of HCPCS code G0498 for these prolonged chemotherapy infusions “where the facility incurred a facility expense specific to the provision of the non-implantable, external infusion pump.” It is good to note that HCPCS code G0498 has the same OPPS status indicator (“S”) and payment rate ($279.45 for 2017) as CPT code 96416. And, CMS made the code retroactive to January 1, 2016.

The full description of HCPCS code G0498 is “Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living).” The code includes the chemotherapy administration service (the IV infusion of the drug), any supplies used, and the cost of using the pump. Providers should not report another code for the chemotherapy infusion – it is covered by this HCPCS code. The chemotherapy drug can be billed separately in addition to the administration code, G0498.

It feels good to win!