CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Chemotherapy Services Billing Guideline

Guideline governing coding, documentation, and reimbursement for chemotherapy, infusion, injection, and hydration services for providers submitting claims to Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChemotherapy Services Billing Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionPhysician must be physically present, review and affirm the treatment plan, and supervise non-physician staff before billing infusion/chemotherapy services.

SourceLink

POLICY UPDATE CHANGES

Format change and minor edits were made on 9/1/2013.

Physician must be physically presentdirect physician oversight required for infusion/injection/chemotherapy codes

Hydration bundledhydration payment bundled when given with chemotherapy administration

Hydration separately payablehydration payable only when sequential or separately medically necessary

Modifiers 25 or 59 acceptableuse to indicate separately identifiable E/M services on same day

Coverage and Billing Criteria for Chemotherapy/Infusion

Chemotherapy and infusion billing criteria

Covered when the following billing, documentation, and supervision requirements are met:

Direct physician oversight required for infusion, injection, and chemotherapy codes; physician must be physically present, review and affirm the treatment plan, and supervise non-physician clinical staff. Ancillary staff (RN, LPN) may not bill if the physician is not present.

ALL of the following

Use of local anesthetic
IV access
Access to an indwelling IV, subcutaneous catheter or port

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyChemotherapy Services Billing Guideline

Policy CodePolicy N/A

Change TypeFormat change and minor edits (9/1/2013)

Effective DateSep 1, 2010

Next Review DateN/A

Key ActionPhysician must be physically present, review and affirm the treatment plan, and supervise non-physician staff before billing infusion/chemotherapy services.

SourceLink

On This Page

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Coding and Billing Details

Infusion/injection/chemotherapy inclusionsmixed

Use of local anesthetic	Use of local anesthetic
IV access	IV access
Access to an indwelling IV, subcutaneous catheter or port	Access to an indwelling IV, subcutaneous catheter or port
Flush at the conclusion of infusion	Flush at the conclusion of infusion
Standard tubing, syringes, and supplies	Standard tubing, syringes, and supplies
Preparation of the chemotherapy agents	Preparation of the chemotherapy agents
Hydration therapy (when administered at same time as chemotherapy)	Payment for hydration therapy is bundled into the payment for chemotherapy drug administration when the infusions are administered at the same time
Fluids used to administer or prepare chemotherapy drugs	Fluids used to administer or prepare the chemotherapy drugs is considered incidental hydration and is not separately reportable
Hydration (sequential or separate medically necessary service)	Hydration is only payable when sequential or as a separate and medically necessary service
Therapeutic, prophylactic and diagnostic injections/infusions	Therapeutic, prophylactic, and diagnostic injections and infusions exclude the administration of chemotherapy agents

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Additional hour billing — inv-03: each additional hour threshold

RulePhysician may report the infusion code for 'each additional hour' only if the infusion is greater than 30 minutes beyond the hour increment.

ApplicabilityApplies to infusion administration codes for chemotherapy, hydration, and injections requiring direct physician oversight.

Documentation implicationTime beyond the hour increment must be documented to support billing the additional hour unit.

Related restrictionAncillary staff (RN/LPN) cannot bill if physician is not physically present; physician must supervise and affirm plan.

Provider Presence, Supervision, and Same-day E/M Rules

Documentation Required

Physician presence, review, and supervision required

All the infusion codes for hydration, injections, and chemotherapy require direct physician oversight. The physician must be physically present, review and affirm the treatment plan, and supervise non-physician clinical staff; if the physician is not present, ancillary staff (RN or LPN) cannot bill for these services.

Physician must be physically present during infusion/injection/chemotherapy services.
Physician must review and affirm the treatment plan and supervise non-physician clinical staff.
Ancillary staff (RN or LPN) cannot bill for these services if the physician is not present.

Billing Rule

Same-day E/M coverage and modifier use (25 or 59)

Evaluation and management services provided the same day as chemotherapy or injections/infusions are covered only if medically necessary and separately identifiable from the other services; use modifier 25 or 59 to indicate a separately identifiable E/M and supporting notes may be required. Note: CPT 99211 should not be billed with a diagnostic or therapeutic injection or infusion.

Same-day E/M must be medically necessary and separately identifiable to be covered.
Use modifier 25 or 59 to indicate a separately identifiable E/M service.
Documentation/notes may be required for review to consider separate payment.
Do not bill 99211 with a diagnostic or therapeutic injection or infusion.

Definitions and Included Services

Incidental hydration — inv-06

DefinitionFluids used to administer or prepare chemotherapy drugs are considered incidental hydration and are not separately reportable.

BundlingPayment for hydration therapy is bundled into the payment for chemotherapy drug administration when infusions are administered at the same time.

When payableHydration is payable only when sequential or provided as a separate, medically necessary service.

Included services/supplies — inv-07

Included itemsUse of local anesthetic is included in infusion/injection/chemotherapy codes and not separately billable.

Vascular accessIV access and access to an indwelling IV, subcutaneous catheter or port are included and not separately billable.

Post‑procedure careFlush at the conclusion of infusion is included and not separately billable.

SuppliesStandard tubing, syringes, and supplies are included and not separately billable.

Drug prepPreparation of the chemotherapy agents is included in the administration codes and not separately billable.