Add-on codes are a headache for many professionals, and rightfully so. Have you also encountered a denial because you weren’t aware of the existence of such a code? Oncologists, especially those giving chemotherapy via intravenous (IV) infusion, might relate to this problem.
Accurately coding the administration of a chemotherapy drug is as important as managing it effectively. You might be an expert at the latter, but if you need help with the former, then this can be your ultimate guide. Follow this blog as we break down CPT code 96415.
CPT Code 96415 – Description
CPT code 96415 is the add-on code. It means it is reported together with a primary code, CPT code 96413. But what does this add-on code specify? It simply reports continuous IV infusion of a chemotherapy drug. In plain language, the 96415 CPT code covers any additional time beyond the first hour of infusion within the same session.
However, there is a trick! It covers extra time in hourly intervals. This means you can only report it once for each additional hour of delivering the chemotherapy drug. Still confused about this hourly reporting? Don’t worry, we will discuss this in detail in the reimbursement guidelines section.
Appropriate Use Cases for CPT Code 96415
Now that we have clarified what CPT code 96415 covers, let’s discuss some of its appropriate use cases:
Reporting Prolonged Chemotherapy Infusion for ILC
Chemotherapy is an effective treatment for almost all types of breast cancer. Therefore, let’s consider a patient who is in chemotherapy to treat invasive lobular carcinoma (ILC), which accounts for 10.6% of all breast cancer diagnoses.
During a scheduled session, an oncologist performs an intravenous administration of a chemotherapy drug for 120 minutes. He reports the first hour with CPT code 96413 and the additional hour with CPT code 96415.
Reporting Two Units of CPT Code 96415
Do you need another example for this code? Here is how you can report another prolonged chemotherapy infusion. Suppose a patient with prostatic adenocarcinoma, the most common type of prostate cancer, accounting for about 95% of cases, is undergoing chemotherapy.
The treatment requires 160 minutes of continuous intravenous drug administration. As usual, the oncologist bills the initial hour with 96413 and reports additional time (1 hour and 40 minutes) with 96415. He specifically reports two units of this add-on code (even though the second additional hour is not complete) because it exceeds 30 minutes.
Billing Prolonged Chemotherapy Infusion for NSCLC
We hope this final use case clarifies the remaining confusion about CPT code 96415. A patient arrives at an outpatient infusion center for his scheduled chemotherapy session. He has lung cancer, specifically Non-Small Cell Lung Cancer (NSCLC), which accounts for 80 to 85% of all cases.
The healthcare provider administers a chemotherapy drug via IV for 125 minutes. After assigning the primary code, he reports the additional time with the 96415 CPT code. In this case, he reports one unit of this add-on code since the second hourly interval is incomplete (less than 30 minutes).
Reimbursement Guidelines for CPT Code 96415
Here are some key tips for billing CPT code 96415:
Always Report 96415 with its Primary Code
Keep this detail in your mind when documenting any add-on code. You cannot bill these codes as standalone services. Want to know the reason? Insurance payers will immediately deny your claim. Hence, always report CPT code 96415 with CPT code 96413.
Apply the Correct Units
Another important thing to remember? CPT code 96415 is reported in units, where each unit represents an additional hour of chemotherapy infusion. But what happens if the IV is completed before a full hour?
Well, you can report it as one unit if the infusion lasts more than 30 minutes beyond the initial hour. For example, if the chemotherapy drug administration lasted for 95 minutes, you can report the first 60 minutes with CPT code 96413 and the remaining 35 minutes as one unit of CPT code 96415.
Record the Duration of Each Infusion
You must have proof of your claim. Therefore, document the start and stop times of each infusion to justify the billed units of CPT code 96415. This step will help you avoid claim denials or payment delays.
Avoid Basic Mistakes
Since CPT code 96415 is an add-on code, you can only use it for continuous infusion of the same chemotherapy drug. Many healthcare providers face reimbursement issues for incorrectly using this code. The best way to avoid billing headaches is to verify all these details, including the set threshold for this code, with specific insurance payers.
Final Thoughts on CPT Code 96415
As you can see, add-on codes are not as complicated as people make them out to be. You just need to report them together with their primary code. CPT code 96415 is one such code for chemotherapy infusion, allowing you to bill for each additional hour of drug administration.
However, you cannot use it to bill for the drug itself. We have outlined clear guidelines to help you report this code accurately. But for more accuracy, you can work with our certified coders. Choose our oncology billing services for guaranteed results and timely reimbursements.
