Summary & Overview
CPT 96405: Intralesional Chemotherapy for One to Seven Lesions
CPT code 96405 denotes intralesional chemotherapy administration to one through seven lesions or tumors and is used to bill for localized chemotherapeutic treatment delivered directly into tumor sites. This code matters nationally because it captures a targeted oncologic procedure that may be performed in multiple ambulatory settings and can affect site-of-service payment differentials, utilization monitoring, and coverage policy development for localized cancer therapies.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of clinical context for intralesional chemotherapy, expected service settings, common modifiers and billing considerations, and national benchmarking and policy implications where available. The publication outlines how payers commonly handle coverage determinations and documentation expectations for lesion-based chemotherapy procedures.
This resource summarizes actionable billing and coding context, clarifies when CPT code 96405 applies, and highlights areas where payers and providers often focus review efforts. Data not available in the input is noted where applicable, and the piece is intended as a concise national reference for coding, reimbursement discussion, and clinical documentation alignment related to intralesional chemotherapy for one to seven lesions.
Billing Code Overview
CPT code 96405 describes the direct administration of chemotherapy into one to seven lesions or tumors during a single session. The procedure involves localized, intralesional chemotherapy delivery aimed at treating discrete tumor sites.
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Service type: Intralesional chemotherapy administration
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Typical site of service: Ambulatory surgical center or hospital outpatient department, or physician office-based procedure room
Clinical & Coding Specifications
Clinical Context
A typical patient is a 62-year-old with metastatic cutaneous squamous cell carcinoma presenting with one to seven palpable or visible cutaneous and subcutaneous tumor nodules. The patient is seen in an outpatient infusion clinic or procedure room. After informed consent, lesion mapping and local anesthesia are performed. The provider injects a cytotoxic agent or chemotherapeutic agent directly into each targeted lesion (one to seven lesions) using sterile technique. Vital signs and comfort are monitored during and after injection. Post-procedure instructions include local wound care, signs of infection or systemic toxicity, and a follow-up visit to assess lesion response and need for additional local or systemic therapy. Typical sites of service are ambulatory infusion centers, hospital outpatient departments, or office-based procedure suites.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the day of a procedure | Use when a distinct E/M is documented on the same day as the intralesional chemotherapy and meets E/M criteria. |