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Code This!

Scenario Week of November 21, 2011:
View Current Scenario

Outpatient Hospital Setting – Chemotherapy
Assign appropriate ICD-9-CM diagnosis and CPT codes.

Severe rheumatoid arthritis involving MCP and PIP joints of fingers of both hands, nodules are present

Brief History:
The patient is a 35 year old female diagnosed with RA two years ago. Due to the extent of the patient’s disease she is disabled. Patient had a Hickman catheter inserted 7/1/11.

Treatment Plan:
IV SoluMedrol 40 mg in NS 30 min prior to Rituximab
Rituximab 1000 mg - 100 mg/hr, increase by 100 mg/hr q30min, not to exceed 400 mg/hr
Methotrexate 20 mg – IVP over 10 min

Physician Note:
Here today for second round of first course of combination therapy. First dose of rituximab was given 8/17. Methotrexate was also started at that time; patient has been titrated to 20 mg per protocol for this encounter.
Patient was stable throughout the encounter with no incident. Discussed follow up and infection risk. She verbalized continued understanding.

Nurses Notes:
0900: Patient examined, vitals are stable. Hickman: WNL. Port accessed and SoluMedrol started.
0920: Infusion complete. Vitals stable.
0935: Rituximab started at 100 mg/hr.
1005: Patient stable, infusion increased 100mg
1040: No change, infusion increased 100mg
1110: No change, infusion increased 100 mg
1230: Infusion complete, line flushed.
1300: Methotrexate administered
1330: Patient stable. Doctor in to see patient.
1430: Discharged with instructions

ICD-9-CM Diagnosis Answers

714.0 Rheumatoid arthritis

Although the encounter is for immunotherapy, it is not for treatment of a neoplasm and therefore ICD-9-CM conventions state the condition should be first listed and code V58.12 (Encounter of antineoplastic immunotherapy) is not appropriate for this claim. Nodules would not be reported because those are inherent to rheumatoid arthritis in its more severe stages. It is important to note that there are Local Coverage Determinations (LCDs) in place for Rituximab in certain areas and special care should be taken to ensure that rheumatoid arthritis is a medically necessary diagnosis for this treatment.

CPT Answers
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)
96411 Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)
96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)

The chemotherapy codes are used for Rituximab although it is not actually chemotherapy. It is in fact an immunotherapeutic drug called a biologic response modifier (BRM) or more specifically a monoclonal antibody. CPT discusses that the administration of monoclonal antibodies and some BRMs are reported using the chemotherapy codes.
Due to this being a facility setting, the CPT hierarchy of infusion and injection codes applies, making chemotherapy the primary service followed by non-chemotherapy although the non-chemotherapy was administered first. The infusion of Rituximab lasted 2 hours and 55 minutes, which is reported with 96413 and 96415 x 2. The methotrexate was administered over ten minutes, which according to CPT guidelines should be reported as an intravenous push because it is 15 minutes or less in duration (96411). Finally, the non-chemotherapy SoluMedrol code also should be reported. The administration of the corticosteroid lasted 20 minutes. Per CPT guidelines an intravenous administration that is greater than 15 minutes should be reported as and infusion. This is a sequential infusion (secondary to the initial infusion) of a new substance making the SoluMedrol administration reported with 96367.

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