Description:
Chemotherapy treatment used for the treatment of cancer is comprised of two components:

• Administration
• Chemotherapy drugs

Administration includes the injection of the drug by the physician, subsequent medical visits rendered with administration services (e.g., subsequent office visit, subsequent hospital visit, follow-up consultation), the monitoring of the patient during administration, line maintenance, supplies (including but not limited to low cost diluents, low cost additives [ex.,vitamins, Methoprednisone, insulin, heparin], syringes, IV solution, IV set, pump). Office chemotherapy administration services are filed using CPT procedure code 96400 through 96549. If a physician has face to face visit prior to the administration of chemotherapy level 3 or higher, office visit may be allowed (99213 – 99215). Type service code 6 is used when treatment is rendered in the physician’s office. Chemotherapy treatment during hospital care should be billed using the appropriate inpatient or outpatient evaluation and management codes.

If hydration is done during the same visit, and not done concurrently with the administration of chemotherapy, physicians may bill for "each additional hour."

If the office visit is for the purpose of line maintenance or flushing the line and there is no other chemotherapy administration, the provider should file the appropriate level of office visit.

Chemotherapy drugs can be taken orally or injected. Oral medications of this type are purchased from the pharmacy and claims for them are filed in the same way as other prescription drugs. If filed by physician, the drug should be processed under the prescription drug program.

When chemotherapy is injected, the patient can obtain the chemotherapy drugs from the physician at the time of administration, or the patient can purchase the drugs from a pharmacy and provide them for the physician to administer.

When the physician provides the chemotherapy drugs for injection, charges are reported using CPT codes J9000 through J9999, or the appropriate HIPAA drug code. When the patient provides the chemotherapy drugs, charges are filed in the same way as oral chemotherapy medications.

Policy:
A physician who provides the injectable chemotherapy drugs and administers the chemotherapy treatment can receive benefits for both services. When the patient supplies the chemotherapy drugs, the physician can receive benefits for the administration only; benefits for the chemotherapy drug charges are paid to the subscriber or pharmacy.

The allowance for chemotherapy administration is defined as the lesser of the two dollar amounts described below:

• The dollar amount allowed by the contracting pricing schedule (dollar amounts are displayed on CRT pricing screens); or
• The physician’s charge for administration.
• Once the allowance is determined, contract percentages and limitations are applied.

Allowances for all chemotherapy drugs — oral or injectable, provided by the patient or physician — are defined as the actual cost to the physician with no markup. Benefits are provided according to contract percentages, limitations and exclusions.

Benefits described in this policy are limited by guidelines established by the patient’s contract, Uniform Medical Policy and the Food and Drug Administration.

This policy applies to chemotherapy drugs and administration only when the patient is being treated for cancer. This policy should not be used to determine benefits for chemotherapy drugs and administration when treatment is rendered for an illness other than cancer.

BlueCross BlueShield of South Carolina recognizes uses and indications of injectable oncology medications (including chemotherapy/therapy, therapeutic radiopharmaceuticals, and selected supportive therapies) to be MEDICALLY NECESSARY if they are listed in the NCCN Drugs and Biologics Compendium with Categories of Evidence + Consensus of 1, 2A and 2B. Treatments listed with a Category of Evidence and Consensus of 3 are considered unproven and NOT MEDICALLY NECESSARY.

NOTE: 

• This policy applies to MD administration chemotherapy. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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