How To Use CPT Code 96405

CPT 96405 describes the administration of chemotherapy directly into a lesion or tumor. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 96405?

CPT 96405 is used to describe the administration of chemotherapy directly into a lesion or tumor. This procedure is typically performed by a healthcare provider to kill fast-growing cells in the body, particularly cancer cells. The chemotherapy is injected directly into the site of the tumor or lesion, such as Kaposi’s sarcoma skin lesions. It is important to note that CPT 96405 is specifically used when treating one to seven lesions.

2. Official Description

The official description of CPT code 96405 is: ‘Chemotherapy administration; intralesional, up to and including 7 lesions.’

3. Procedure

1. The healthcare provider assesses the patient’s condition and determines the need for intralesional chemotherapy.
2. The provider selects the appropriate chemotherapy agents and prepares them for administration.
3. The provider administers the chemotherapy directly into the tumor or lesion site using a syringe or other appropriate method.
4. If there are multiple lesions, the provider repeats the administration process for each lesion, up to a total of seven.
5. The provider monitors the patient for any immediate adverse reactions or side effects.
6. Additional sessions may be scheduled as needed to continue the intralesional chemotherapy treatment.

4. Qualifying circumstances

CPT 96405 is used when a patient requires chemotherapy administration directly into a lesion or tumor. This procedure is typically performed for patients with cancer or other conditions that require the targeted delivery of chemotherapy to specific sites. The provider must administer the chemotherapy to one to seven lesions, and the treatment must be medically necessary and appropriate for the patient’s condition.

5. When to use CPT code 96405

CPT code 96405 should be used when a healthcare provider administers chemotherapy directly into one to seven lesions or tumors. It is important to ensure that this procedure is medically necessary and appropriate for the patient’s condition. If the provider administers chemotherapy into more than seven lesions, CPT code 96406 should be used instead.

6. Documentation requirements

To support a claim for CPT 96405, the healthcare provider must document the following information:

• The patient’s diagnosis and the medical necessity of intralesional chemotherapy
• The specific chemotherapy agents used for the treatment
• The number of lesions or tumors treated during the session
• The date and time of the administration
• Any immediate adverse reactions or side effects observed
• Any additional sessions scheduled for ongoing treatment
• The provider’s signature and credentials

7. Billing guidelines

When billing for CPT 96405, ensure that the procedure meets the criteria for intralesional chemotherapy administration. The provider should administer chemotherapy directly into one to seven lesions or tumors. It is important to follow the specific guidelines and rules set by the payer for accurate billing. Additionally, it is crucial to review any bundling or unbundling rules that may apply to ensure proper reimbursement.

8. Historical information

CPT 96405 was added to the Current Procedural Terminology system on January 1, 1994. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A healthcare provider administers chemotherapy directly into a skin lesion of a patient with melanoma.
2. A provider injects chemotherapy into a tumor in the liver of a patient with liver cancer.
3. A healthcare professional administers chemotherapy into multiple lesions in the lungs of a patient with lung cancer.
4. A provider treats several lesions on the scalp of a patient with basal cell carcinoma using intralesional chemotherapy.
5. A healthcare provider administers chemotherapy directly into a tumor in the breast of a patient with breast cancer.
6. A provider injects chemotherapy into a lesion on the tongue of a patient with oral cancer.
7. A healthcare professional treats multiple lesions on the skin of a patient with cutaneous lymphoma using intralesional chemotherapy.
8. A provider administers chemotherapy directly into a tumor in the bone of a patient with bone cancer.
9. A healthcare provider treats several lesions on the face of a patient with squamous cell carcinoma using intralesional chemotherapy.
10. A provider injects chemotherapy into a tumor in the brain of a patient with brain cancer.