Did you know that every 1 in 8 women lives with the chance of developing breast cancer once in their lifetime? And every 1 in 8 men will be diagnosed with prostate cancer once in their lifetime? Both cancers occur, and their growth is fueled because of male and female hormones. For this reason, a physician injects various drugs to control hormones that work as a catalyst in such cases.
CPT code 96402 talks about this procedure, where the physician conducts chemotherapy with hormonal anti-neoplastic drugs (used to control hormones causing cancer). However, we are here to discuss the correct way to bill this code. Read this comprehensive blog to find out the details.
CPT Code 96402 – Description
CPT code 96402 reports the administration of hormonal anti-neoplastic drugs during chemotherapy via subcutaneous or intramuscular injection. The procedure treats hormone-sensitive cancer and prevents it from further growth.
Scenarios Where CPT Code 96402 is Applicable
The following are some scenarios where 96402 accurately applies.
Prostate Cancer
Suppose a man suffering from prostate cancer comes to the oncology clinic. The physician decides to give him a dose of leuprolide acetate (Lupron Depot). A trained medical professional administers the injection intramuscularly into the gluteal muscle. This drug will stop the testicles from making testosterone, which promotes cancer growth. Hence, the physician can apply CPT code 96402 for the intramuscular administration of a hormonal anti-neoplastic agent.
Breast Cancer
Imagine a 40-year-old woman in her pre-menopause was diagnosed with breast cancer. Her oncologist decides to inject a goserelin acetate (Zoladex) drug because there are cells of hormone receptor-positive breast cancer. The injection is administered subcutaneously in her lower abdomen. This injection fits the requirements for CPT code 96402. So, the physician may bill his services with this code.
Endometrial Cancer
Suppose a 55-year-old woman is diagnosed with a uterine cancer. The provider conducts her chemotherapy session with leuprolide acetate (Lupron Depot) intramuscularly once every four weeks. An oncologist oversees a nurse who administers the injection in a clinically controlled environment. This drug helps reduce the progression of endometrial cancer by lowering estrogen levels. Since the patient with recurring or advanced endometrial cancer receives injections of depot hormonal treatment, CPT code 96402 is applicable.
Applicable Modifiers for CPT Code 96402
You can apply the following modifiers when billing for CPT code 96402.
Modifier 59
You may apply modifier 59 to CPT code 96402 if the injection is a separate and distinct service from another procedure performed on the same day.
Modifier JW
The JW modifier is applied to indicate the amount of a drug or biological that is discarded and qualifies for reimbursement under the discarded drug policy. However, you must append this modifier to the HCPCS product/drug code and not to CPT 96402.
Modifier JZ
The JZ modifier explains that zero or none of the drug was discarded. Again, it should be appended to the correct HCPCS product code to indicate that there was no wastage of the drug from a single-dose container.
CPT Code 96402 – Billing & Reimbursement Guidelines
You can check the following reimbursement and billing guidelines for CPT code 96402 to avoid denials.
Ensure the Correct Use of 96402
It is equally imperative to understand scenarios where CPT code 96402 is not appropriate. For instance, if a patient is receiving a hormonal dose but not for the treatment of cancer, then you may apply another related code. Similarly, if the medication is administered through an intravenous (IV) infusion or push, you cannot bill services with 96402. It is exclusively reserved for intramuscular or subcutaneous administration of hormonal anti-neoplastic agents.
Include Detailed Documentation
It is essential to keep thorough records for CPT code 96402 to prevent any denials. The documentation for your claim must contain the following information:
- The medical history of the patient
- Type of medication administered
- Amount of dosage
- Lot number
- Injection site
- Necessity for the administration
- Signature of the provider
Append Appropriate HCPCS Codes
Your CPT code 96402 claim must also include the relevant HCPCS product code to explain to the payer which hormonal anti-neoplastic drug was injected. For example:
- J1950: Injection, leuprolide acetate (for depot suspension), per 3.75 mg
- J9217: Leuprolide acetate (for depot suspension), 7.5 mg
- J9202: Goserelin acetate implant, per 3.6 mg
- J3315: Injection of triptorelin pamoate, 3.75 mg
- J1952: Camcevi (leuprolide) injectable, 1 mg
- J1954: Leuprolide acetate, depot suspension (lutrate depot), 7.5 mg
Follow Payers’ Policies
Last but not least, you must check the respective payers’ policies before submitting your claims to them. You must comply with their policies, check their payment schedule, the modifiers they allow, and what HCPCS codes you can apply to the situation. All these steps will save you from claim denials.
Conclusion
We hope we have successfully given you all the information required for the billing of CPT code 96402. Code 96402 represents the administration of hormonal anti-neoplastic chemotherapy injections. The drug is given either subcutaneously (under the skin) or intramuscularly (into the muscle). You may use this code for the treatment of various cancers, such as prostate, breast, or endometrial. The billing guidelines included in this blog will likely help you file accurate claims and secure rightful reimbursements.
However, if you are still perplexed about the billing of CPT 96402, you can outsource oncology billing services. Such service stacks usually include error-free CPT coding.
