Medical Policy

Effective Date:08/01/2008

Title:Infusion Codes

Revision Date:

Document:BI006:00

CPT Code(s):A4206-A4232, 96360-96379, 96401-96549

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) QualChoice covers infusions of medications in participating physicians’ offices, participating infusion centers, and participating hospital outpatient departments.

2) This policy restates rules that are present in the national standard coding books about what services are included in the infusion charges.

Medical Statement

1) The following wording appears in the CPT book in the general description of “Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy)” and again in the general description of “Chemotherapy Administration”

a) “If performed to facilitate the infusion or injection, the following services are included and are not reported separately:

i) “Use of local anesthesia

ii) “IV start

iii) “Access to indwelling IV, subcutaneous catheter or port

iv) “Flush at conclusion of infusion

v) “Standard tubing, syringes and supplies.”

2) In view of this definitional statement, charges for syringes, needles, tubing, infusion sets and supplies will not be paid by QualChoice, as the pricing for the infusions clearly is intended to cover these items.

Codes Used In This BI:

A4206	1 CC sterile syringe&needle
A4207	2 CC sterile syringe&needle
A4208	3 CC sterile syringe&needle
A4209	5+ CC sterile syringe&needle
A4210	Nonneedle injection device
A4211	Supp for self-adm injections
A4212	Non coring needle or stylet
A4213	20+ CC syringe only
A4215	Sterile needle
A4216	Sterile water/saline, 10 ml
A4217	Sterile water/saline, 500 ml
A4218	Sterile saline or water
A4220	Infusion pump refill kit
A4221	Maint drug infus cath per wk
A4222	Infusion supplies with pump
A4223	Infusion supplies w/o pump
A4230	Infus insulin pump non needl
A4231	Infusion insulin pump needle
A4232	Syringe w/needle insulin 3cc
96360	Hydration iv infusion init
96361	Hydrate iv infusion add-on
96365	Ther/proph/diag iv inf init
96366	Ther/proph/diag iv inf addon
96367	Tx/proph/dg addl seq iv inf
96368	Ther/diag concurrent inf
96369	Sc ther infusion up to 1 hr
96370	Sc ther infusion addl hr
96371	Sc ther infusion reset pump
96372	Ther/proph/diag inj sc/im
96373	Ther/proph/diag inj ia
96374	Ther/proph/diag inj iv push
96375	Tx/pro/dx inj new drug addon
96376	Tx/pro/dx inj same drug adon
96379	Ther/prop/diag inj/inf proc
96401	Chemo anti-neopl sq/im
96402	Chemo hormon antineopl sq/im
96405	Chemo intralesional up to 7
96406	Chemo intralesional over 7
96409	Chemo iv push sngl drug
96411	Chemo iv push addl drug
96413	Chemo iv infusion 1 hr
96415	Chemo iv infusion addl hr
96416	Chemo prolong infuse w/pump
96417	Chemo iv infus each addl seq
96420	Chemo ia push tecnique
96422	Chemo ia infusion up to 1 hr
96423	Chemo ia infuse each addl hr
96425	Chemotherapy infusion method
96440	Chemotherapy intracavitary
96446	Chemotx admn prtl cavity
96450	Chemotherapy into cns
96521	Refill/maint portable pump
96522	Refill/maint pump/resvr syst
96523	Irrig drug delivery device
96542	Chemotherapy injection
96549	Chemotherapy unspecified

Limits

Intentially left empty

Reference

Intentially left empty

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.