Treating cancer is not simple. There are several types of cancers and tumors with varying stages. Thus, each patient needs a thorough examination before oncologists design an effective treatment plan based on their unique condition. All these factors make oncology billing and coding more complicated than other specialties.
Therefore, we have dedicated this guide to discussing oncology CPT codes. We will share descriptions of commonly used codes for chemotherapy procedures, injections, and radiation therapies to help you understand when to report each code. We will also share oncology billing and coding best practices to help you streamline your revenue cycle.
Let’s get started with understanding the common CPT codes for oncology billing for chemotherapy administration, therapeutic, prophylactic, and diagnostic injections, and radiation services:
Oncology CPT Codes for Chemotherapy Administration
Following are the commonly reported oncology CPT codes for chemotherapy administration:
CPT Code 96409 – Chemotherapy Administration, Intravenous Push Technique
You can bill this oncology CPT code when the healthcare provider uses an intravenous push (IV push) technique for a chemotherapy drug (single or initial drug). The provider may administer a single dose through a syringe.
For the unversed, IV push is a technique that enables the practitioner to release medication or fluid substances directly into the patient’s bloodstream through the venous system. Besides, this type of chemotherapy works more quickly than topical and oral methods.
CPT Code 96411 – Chemotherapy IV Push Administration of Additional Drugs/Substances
It is an add-on oncology CPT code that you may report to bill for IV push administration of additional drugs/substances at the same session.
CPT Code 96413 – Chemotherapy Administration, Intravenous Infusion Technique
This oncology procedure code covers the chemotherapy administration using the intravenous infusion technique. Chemotherapy is a therapeutic medical procedure that oncologists order to treat cancer patients with the help of chemical agents. Besides, these drugs destroy the cancer cells in the patient’s body.
There are multiple techniques to administer the drug, including intraventricular, subcutaneous, oral, topical, intraperitoneal, intra–arterial, intramuscular, intravenous, and subcutaneous. However, the intravenous approach is most widely used because it ensures quick drug absorption in the patient’s bloodstream.
Contrary to IV push, the infusion technique may last from a few minutes to several hours as the drug release is minutely controlled by the provider from a plastic bag through the tubing attached to the catheter. However, this CPT code covers only the initial first hour of administration.
CPT Code 96415 – Chemotherapy IV Infusion Administration of Additional Drugs/Substances
You can report this CPT code for oncology billing for each additional hour the healthcare provider administers the drug infusion to treat the cancer patient.
CPT Code 96417 – Chemotherapy Administration, Each Additional Sequential Infusion of A Different Drug
It is also an add-on CPT code for oncology billing. However, it covers the chemotherapy administration through IV infusion, where a different drug/substance is used after an initial dose.
Oncology CPT Codes for Therapeutic, Prophylactic, and Diagnostic Injections
Oncologists often administer injections for diagnostic, prophylactic, or therapeutic purposes in the treatment of cancer patients. Some of the common CPT codes for oncology billing are discussed below:
CPT Code 96372 – Therapeutic, Prophylactic, or Diagnostic Injection
You may report this oncology CPT code for injecting a diagnostic, prophylactic, or therapeutic substance (a drug, fluid, etc.) through an intramuscular or subcutaneous route into the patient’s body.
The physician can perform this procedure himself, or the nurse or assistant may inject the medication under the physician’s direct supervision. However, this code does not cover toxoid or vaccine injections.
CPT Code 96365 – Intravenous Infusion, For therapy, Prophylaxis, or Diagnosis, Initial 1 Hour
Use this CPT code for oncology billing when the healthcare provider administers the initial IV infusion of a medication or other substance for one hour to diagnose, prevent, or treat a disease or condition.
CPT Code 96366 – Intravenous Infusion, For therapy, Prophylaxis, or Diagnosis, Each Additional Hour
Use this oncology CPT code when the healthcare provider administers the IV infusion of a medication or other substance for subsequent hours to diagnose, prevent, or treat a disease or condition after the initial hour.
Radiation Oncology CPT Codes
Radiation therapy effectively treats cancerous tumors. Thus, this section will discuss a few commonly used radiation oncology CPT codes that oncologists leverage:
CPT Code 77300 – Basic Radiation Dosimetry Calculation
Radiation therapy is helpful to prevent the cancer from spreading. However, it has a few side effects, like damaging healthy cells. Thus, oncologists perform thorough planning before the onset of the radiation treatment, i.e., the dosage volume, duration, and technique used.
Dosimetry calculates the duration and amount of radiation required to treat malignancy successfully. The unit used to measure the dose is known as ‘grays’ (Gy), and it varies depending upon the cancer type and stage. Besides, radiotherapy involves planning and calculation for several factors, including non–ionizing radiation surface, central axis depth dose, tissue inhomogeneity factor, gap calculation, time dose factor (TDF), nominal standard dose (NSD), off-axis factor, and depth dose.
Moreover, the physician may modify the treatment dosage by ordering subsequent dosimetries based on the treatment outcome and bill it under the oncology CPT code 77300.
CPT Code 77295 – Computer–generated Radiographic Reconstruction
Oncologists often order three-dimensional (3D) imaging or computer-generated radiographic reconstruction for accurate assessment of the tumor’s extent, location, and size, treatment planning, and monitoring of the response to treatment.
You may report oncology CPT code 77295 to bill for volumetric dose calculation and computer-generated radiographic reconstruction to enhance the external beam radiation administration precision. However, you must ensure complete documentation, including dose distribution, 3D volume reconstruction, 3D dose calculation summary in graph form, and dose volume histograms to prevent payment delays or denials.
CPT Code 77427 – Ionizing Radiation Beam Therapy
The oncology procedure code covers using ionizing radiation beams to destroy cancer cells, i.e., the radiation damages the genetic material (DNA) in the cancerous cells, preventing its growth.
Thus, this treatment may risk damaging the normal cells in the patient’s body. However, oncologists reduce this risk by utilizing highly advanced equipment that directs the radiation beam precisely and accurately to the affected cells.
Oncologists may order this therapy to treat several types of cancer, including certain non–malignant conditions, lymphomas, leukemia, and malignant tumors of different organs.
There are two types of radiation therapies, i.e., external radiation therapy, in which the source remains outside the patient’s body, and internal radiation therapy (brachytherapy), in which the source is placed internally.
Oncology Coding Guidelines
This section comprehensively discusses oncology coding and billing best practices to help you improve your practice’s financial health:
Ensure Accurate Documentation
Complete and adequate documentation is the key to ensuring your claim gets reimbursed on the first try. Insurance payers demand you justify the medical necessity and appropriateness of the treatment for cancer patients through detailed charting, test results, and supporting information.
Verify Insurance Eligibility and Coverage
Verifying the patient’s insurance eligibility and coverage details, such as copays, benefits, and deductibles, by contacting the insurance company should be a priority before providing oncology services. Thus, we advise you to make it a standard practice as it ensures timely reimbursements and a steady cash flow.
Meet the Claim Filing Deadline
Payers have strict deadlines when it comes to accepting claims. Failure to meet the timeline can result in financial losses for your oncology practice. Thus, we recommend implementing an automated claim tracking system to ensure timely claim submissions, reducing the strain on your revenue cycle.
Comply with Regulations
The healthcare industry is in constant flux as new rules and regulations are introduced by the state and federal government and other regulatory authorities, like HIPAA. Besides, the insurance companies also have varying billing requirements. You must comply with state and federal laws and specific payer requirements to ensure you receive timely reimbursements and avoid tarnishing your oncology practice’s reputation in the process.
Follow the Coding Standards
Coding accuracy and specificity are significant in ensuring claim first pass rate. Medical coding systems are complex and confusing as there are hundreds of codes for oncology with descriptions that vary slightly. Besides, choosing the wrong oncology procedure code (intentionally or by mistake) may put you in hot waters, resulting in denials, financial penalties, and legal lawsuits.
Thus, if you can afford it, we recommend you hire certified professional coders (CPCs) to handle the oncology coding requirements or outsource the process to professionals.
Bottom Line
The common oncology CPT codes cover chemotherapy administration, such as 96409, 96411, 96413, 96415, and 96417, therapeutic, prophylactic, and diagnostic Injections, for example, codes 96372, 96365, and 96366, and radiation services, like basic radiation dosimetry calculation, computer-generated radiographic reconstruction, and ionizing radiation beam therapy.
Following oncology coding and billing best practices like accurate documentation, eligibility verification, regulatory compliance, and precise coding can help you receive your rightful reimbursements against your rendered services. However, if you still find it challenging, you can outsource oncology billing services to MediBill MD.
