Health Information Management

Q/A: Billing for six-hour chemotherapy infusion

APCs Insider, July 23, 2010

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Q: How should we bill a patient for a six-hour chemotherapy infusion? The patient occupies an inpatient bed. Should we bill this as observation or as an outpatient clinic visit? If we bill this as observation, do we need a complete chart including patient assessment and physician’s notes or just a clinic visit note?

A: If the patient undergoes an ordered chemotherapy infusion that lasts six hours, proper billing is for chemotherapy service using the correct drug administration codes and number of units in accordance with CPT coding guidelines. Bill the CPT codes under the appropriate revenue code, e.g.,0761 (treatment room) or 0335 (chemotherapy administration –IV). Room services are included in the chemotherapy payment and generally are billed as part of the charge for chemotherapy.

Billing for observation at the same time as chemotherapy would be inappropriate. The Medicare Claims Processing Manual, Chapter 4, Section 290.2.2, states that this service requires active monitoring and that billing observation at the same time is inappropriate. An outpatient clinic visit (i.e., billed with a visit E/M code) would also be inappropriate unless services significant and separately identifiable from the chemotherapy were provided.

Documentation should demonstrate the medical necessity of the service. It also should include an order for the service, IV site, and stop and start times, and any other documentation your medical staff has deemed appropriate for an outpatient.

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