2025 CPT code 96406
(Active) Effective Date: N/A Revision Date: N/A Medicine - Chemotherapy Administration and Other Highly Complex Drug or Highly Complex Biologic Agent Administration Medicine Services and Procedures > Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration Feed
Chemotherapy administration; intralesional, more than 7 lesions.
Modifiers may be applicable depending on the circumstances of service. Consult the CPT manual and payer guidelines for modifier usage. Modifier 59 (Distinct Procedural Service) might be appropriate if the service is distinct from other services provided on the same date.
Medical necessity for 96406 is established when the physician documents that intralesional chemotherapy is the appropriate treatment for the patient's condition, specifically when it involves more than seven lesions. This should be supported by clinical findings, imaging studies, and the patient's overall health status. The number of lesions treated must be clearly documented to justify the selection of this code over CPT code 96405.
The clinical responsibility for 96406 lies with the physician or other qualified healthcare professional administering the intralesional chemotherapy. This includes assessing the patient, obtaining informed consent, selecting the appropriate chemotherapy agent and dose, preparing the injection, injecting the chemotherapy into the lesions, monitoring the patient for adverse reactions, and providing post-procedure care. Direct supervision of staff involved in the preparation or administration of chemotherapy may be required depending on facility policies and patient condition.
- Medicine Services and Procedures > Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration
- Chemotherapy Administration and Other Highly Complex Drug or Highly Complex Biologic Agent Administration
In simple words: This code is for when a doctor injects chemotherapy medicine directly into more than 7 tumors or sores on the skin or body.The medicine is injected into the affected areas themselves, not given through an IV or pill.
This CPT code, 96406, reports the intralesional administration of chemotherapy to more than seven lesions.Intralesional chemotherapy involves the direct injection of chemotherapeutic agents into a tumor or lesion. This procedure is distinct from systemic chemotherapy, which circulates throughout the body. The code specifically applies when more than seven lesions are treated during a single session.Preparation of the chemotherapy agent(s) is included and not separately reported.
Example 1: A patient presents with multiple Kaposi's sarcoma lesions on the skin. The physician injects chemotherapy into more than 7 lesions. Code 96406 is used., A patient with metastatic melanoma has numerous skin nodules. The oncologist performs intralesional chemotherapy injection into more than 7 lesions. Code 96406 is reported., A patient with recurrent basal cell carcinomas has more than 7 lesions that are treated with intralesional chemotherapy. The dermatologist uses code 96406 to bill the procedure.
Detailed medical record documentation is required to support the use of CPT code 96406. This includes:
** The number of lesions treated is the critical factor differentiating this code (96406) from 96405. Always verify the number of lesions treated to ensure accurate coding.Always consult the most recent CPT manual and payer guidelines for the most accurate coding and reimbursement information.
- Revenue Code: P7B (ONCOLOGY - OTHER)
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is not typically applicable to this code, as it represents a complete professional service.
- Specialties:Oncology, Dermatology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center