CPT Code 96413 Description & Reimbursement Guidelines

Medical billing is hard, and the complexity of some CPT codes makes the process even more difficult. Did you know that 42% of claim denials occur because of coding errors? CPT code 96413 is among such codes, and billers frequently get it wrong. For accurate billing of 96413, you must have specific knowledge of its application, documentation requirements, and billing guidelines. 

That’s why our billing experts at NeuraBill have compiled this comprehensive guide on CPT code 96413. From detailed code descriptions to modifier usage and documentation best practices, this guide covers everything. So, let’s start. 

CPT Code 96413 Description

According to the official American Medical Association (AMA), CPT code 96413 represents “Chemotherapy administration, intravenous infusion technique; and up to 1 hour, single or initial substance/drug.”

Key characteristics of CPT code 96413 are:

• Time-based service: It is specifically used for chemotherapy administration lasting between 16 and 90 minutes (up to 1 hour).
• Initial service code: It represents the first hour of chemotherapy administration for a single or initial substance/drug.
• Administration method: The code is specifically for the intravenous (IV) infusion technique.
• Complex drug administration: Beyond traditional chemotherapy agents, this code can be used for certain complex biologic agents administration via the IV infusion route.

Please note that the CPT code 96413 is exclusively used for chemotherapy infusions or medicines that are used in both chemotherapy and other treatments. Never use this code for supplementary forms of IV pushes. This is a common mistake that many billers make. Always carefully select the correct code for your specific service type. For simple intravenous infusions, you can use other more relevant codes like 96365 or 96375.

Appropriate Use Cases for CPT Code 96413

To better understand the correct usage of CPT code 96413, let’s look at some real-world scenarios where it can be used. 

Standard Oncology Applications

The most common use of CPT code 96413 is in oncology (cancer) treatments. Healthcare providers frequently use 96413 to bill the initial hour of intravenous administration of antineoplastic drugs for cancer treatment. For example, this code can be used for:

• Cisplatin delivery for patients with lung malignancies
• Infusion of doxorubicin for breast cancer
• Paclitaxel administration in ovarian cancer treatment regimens

Non-Cancer Treatments Using Antineoplastic Medications

Healthcare providers sometimes use CPT code 96413 to administer antineoplastic agents to treat non-cancer conditions. Some examples of these conditions can be:

• Cyclophosphamide for autoimmune disorders
• Methotrexate infusions for severe, treatment-resistant rheumatoid arthritis
• Mitoxantrone for multiple sclerosis

Monoclonal Antibody Administration

You can also use CPT code 96413 for the administration of monoclonal antibodies. This applies to both cancerous and non-cancerous diagnoses. For instance, some examples can be:

• Rituximab for non-Hodgkin’s lymphoma management
• Infliximab for rheumatoid arthritis 

Modifiers to Append with CPT Code 96413

The following modifiers are most commonly appended to CPT code 96413 to provide supplemental information to the insurance payers. 

Modifier	Description	Example Usage
59 Modifier (Distinct Procedural Service)	This modifier may be needed when IV infusion of a chemotherapy drug or other complex biologic agent is performed with another procedure or service not usually reported with CPT 96413.	Modifier 59 may be appended to CPT 96413 when another service was performed on the same day or in the same session before the IV infusion.
XS, XP, XU, XE Modifiers (Medicare X Modifiers)	These are more specific versions of modifier 59 that Medicare may require:XS: Separate structureXP: Separate practitionerXU: Unusual non-overlapping serviceXE: Separate encounter	If a chemotherapy infusion and another service were provided during separate encounters on the same day, modifier XE might be appropriate.

Reimbursement Guidelines for CPT Code 96413

Attention to detail is vital to file a claim with CPT code 96413. Even small mistakes can lead to claim denials. The appeals process is painstaking and results in reduced cash flow. So, follow the guidelines below to boost your chances of successful reimbursement. 

Maintain Detailed Documentation

Proper documentation is the key to medical billing. Most of the claim denials occur due to insufficient documentation or when the healthcare providers fail to justify the need for a procedure or service. Comprehensive documentation serves as a lawyer for your claims. For CPT code 96413, documentation must include:

• Physician’s order for the chemotherapy or complex biologic agent
• Drug name and dosage administered
• Precise start and stop times of the infusion (must be between 16 and 90 minutes)
• Administration route (must be intravenous infusion)
• Patient’s response to the treatment
• Any complications, reactions, or interventions performed
• Nursing notes regarding preparation, administration, and monitoring

Please note that if you don’t mention start and stop times, you can only use CPT code 96409 to bill the procedure, regardless of the actual duration of the infusion.

Follow the Coding Hierarchy and Rules

For infusions and injections, the AMA has a standard billing procedure. The infusion hierarchy determines which code should be reported as the initial service:

• Chemotherapy services (96413) are prioritized over therapeutic, prophylactic, and diagnostic services.
• Therapeutic, prophylactic, and diagnostic services take precedence over hydration.
• IV infusions take precedence over IV pushes, which take precedence over injections.

Therefore, you can only bill one “initial” service code per vascular site each day based on this hierarchy. The only exception occurs when medical protocol requires using two separate IV sites.

Bill the Drug and Dosage Separately 

An important point to note for code 96413 claims is that the drugs administered are billed separately from the administration service using appropriate HCPCS J-codes or NDC numbers. If the entire medicine (vial) was not used, you can mention this in your claim by using the relevant modifiers like JW with the appropriate HCPCS drug code. 

Final Thoughts on CPT Code 96413

CPT code 96413 is an essential and frequently used oncology code. For proper reimbursements, it is vital to provide comprehensive documentation. Also, follow the guidelines mentioned in this guide to maximize your success rate. 

If you need support for medical billing, consider consulting our billing experts at NeuraBill. We provide premium oncology billing services to practices of all sizes.  

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