2025 CPT code 96549
Unlisted chemotherapy procedure.
Modifier 22 (Increased Procedural Services) may be applicable if the procedure is substantially more complex than typically represented by 96549. Modifier 59 (Distinct Procedural Service) might be necessary to distinguish the unlisted procedure from other services performed on the same day.
Medical necessity for the unlisted chemotherapy procedure must be clearly documented. This includes the diagnosis being treated, the rationale for using this specific treatment, and the expected clinical benefit. Documentation should also explain why established, listed chemotherapy codes are not appropriate for the specific clinical scenario.
The physician or other qualified healthcare professional is responsible for the performance and documentation of the unlisted chemotherapy procedure. This includes patient assessment, treatment planning, administration of the chemotherapy, monitoring for adverse reactions, and providing appropriate follow-up care.
In simple words: This code is used for chemotherapy treatments that don't have their own specific code. It's for unusual or uncommon chemotherapy procedures.
This code is used to report chemotherapy procedures that are not described by any other specific CPT code.It is essential to submit supporting documentation with claims using this code, including a detailed description of the procedure performed, the clinical rationale, and the time and resources involved. This information helps justify the billed amount.
Example 1: A patient receives a new type of chemotherapy drug not yet listed in the CPT code set. The administration and monitoring of this drug are reported with 96549., A patient undergoes hyperthermic intraperitoneal chemotherapy (HIPEC) combined with cytoreductive surgery. The HIPEC procedure is reported using 96547, 96548 (for additional time), and 96549 may be used to encompass the overall procedure or additional unique aspects not captured by 96547/96548., A patient with a rare cancer requires a customized chemotherapy regimen involving a combination of drugs and delivery methods not covered by existing CPT codes. The administration of this specialized regimen is reported using 96549.
Detailed documentation is crucial for 96549 and should include the following: 1. A complete description of the procedure performed, including the drug(s) used, dosage, route of administration, and any unique aspects of the treatment. 2. The clinical indication for the unlisted procedure, explaining why established codes are not applicable. 3. The time spent administering the chemotherapy and any associated monitoring or management activities. 4. Documentation of any adverse reactions and their management. 5. Supporting documentation such as operative reports, progress notes, and medication records.
** Always check for newly released or revised CPT codes that may specifically describe the procedure before using 96549.Contact the payer for specific billing and documentation guidelines for unlisted codes, as requirements may vary.
- Revenue Code: Y1 - OTHER - MEDICARE FEE SCHEDULE
- Specialties:Medical Oncology, Hematology, Surgical Oncology, and other specialties administering chemotherapy.
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office, Ambulatory Surgical Center, and other facilities where chemotherapy is administered.