Summary & Overview
CPT 96406: Chemotherapy Administration, Intralesional for More Than 7 Lesions
CPT code 96406 represents the intralesional administration of chemotherapy for patients with more than seven lesions, a procedure frequently utilized in medical oncology and dermatology. This code is significant for its role in treating complex cases of skin malignancies, including melanoma and other neoplasms, where multiple lesions require targeted therapy. Nationally, the code is recognized by major payers such as Aetna, Blue Cross Blue Shield, Cigna Health, Medicare, and UnitedHealthcare, ensuring broad coverage across commercial and government insurance plans.
This publication provides a comprehensive overview of 96406, including payer coverage, clinical context, and policy considerations. Readers will gain insights into typical sites of service, relevant clinical indications, and associated billing practices. The analysis also highlights common modifiers and related codes, offering clarity on procedural distinctions and documentation requirements. Benchmarks and policy updates are discussed to inform stakeholders about current trends and regulatory changes affecting reimbursement and utilization. The information is designed to support healthcare professionals, administrators, and policy analysts in understanding the national landscape for intralesional chemotherapy administration involving multiple lesions.
CPT Code Overview
CPT code 96406 is used to report the administration of chemotherapy directly into lesions, specifically when more than seven lesions are treated during a single session. This procedure is commonly performed in the fields of medical oncology and dermatology, targeting patients with multiple skin neoplasms or malignancies. The typical site of service for this code includes outpatient hospital settings and physician offices (Place of Service codes 11 and 22). The code reflects a higher complexity due to the number of lesions treated, distinguishing it from similar codes used for fewer lesions.
Clinical & Coding Specifications
Clinical Context
A patient presents to a medical oncology or dermatology clinic with multiple malignant skin lesions, such as melanoma or other specified neoplasms. The provider determines that intralesional chemotherapy is appropriate due to the number and distribution of lesions. During the outpatient visit (typically in a hospital outpatient department or physician office), the provider administers chemotherapy directly into more than 7 lesions using an intralesional technique. This procedure is performed by a physician specializing in hematology, oncology, or pediatric hematology-oncology. The workflow includes lesion identification, preparation, intralesional injection, and post-procedure monitoring.
Coding Specifications
-
Modifier
59: Used to indicate a distinct procedural service, such as when intralesional chemotherapy is performed separately from other procedures on the same day. -
Modifier
51: Used to denote multiple procedures performed during the same session, such as when more than one chemotherapy administration code is reported.
| Modifier Code | Description |
|---|---|
59 | Distinct Procedural Service |
51 | Multiple Procedures |
- Provider Taxonomies:
| Taxonomy Code | Specialty |
|---|---|
207RH0003X | Hematology & Oncology Physician |
207RX0202X | Medical Oncology Physician |
207ZP0102X | Pediatric Hematology-Oncology Physician |
Related Diagnoses
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C44.99- Other specified malignant neoplasm of skin- Relevant for patients with skin cancers that are not otherwise specified, often treated with intralesional chemotherapy.
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C43.9- Malignant melanoma of skin, unspecified- Used for patients diagnosed with melanoma, a common indication for intralesional chemotherapy.
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D03.9- Melanoma in situ, unspecified- Indicates early-stage melanoma, which may be treated with localized chemotherapy.
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C79.9- Secondary malignant neoplasm of unspecified site- Applies when skin lesions are metastatic from another primary site, warranting intralesional treatment.
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D49.2- Neoplasm of unspecified behavior of bone, soft tissue, and skin- Used for lesions where the behavior (benign vs malignant) is not clearly defined, but intralesional therapy is considered.
Related CPT Codes
96405- Chemotherapy administration; intralesional, up to and including 7 lesions
96405 is used when intralesional chemotherapy is administered to 7 or fewer lesions. In clinical workflow, 96405 and 96406 are mutually exclusive based on the number of lesions treated. If a patient has more than 7 lesions, 96406 is reported. These codes are not typically used together for the same patient encounter, but may be alternatives depending on lesion count.
National Reimbursement Benchmarks
For CPT 96406, the national mean rate for Medicare is $137.40, while the BUCA (average commercial) mean rate is $125.03. This places Medicare slightly above the commercial average, with individual commercial payers such as UnitedHealth Group and Cigna reporting higher mean rates at $155.64 and $147.26, respectively.
Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Aetna exhibits the tightest range at $48.00, indicating less variability in rates. In contrast, UnitedHealth Group shows the widest dispersion at $71.33, reflecting greater variability in reimbursement amounts. Blue Cross Blue Shield and Cigna also display substantial ranges, at $65.04 and $72.50, respectively.
The table and chart below present the full breakdown of national benchmarks for CPT 96406 across major payers.
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