2025 CPT code 96416
(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
Initiation of a prolonged chemotherapy infusion (more than 8 hours) using a portable or implantable pump.
Modifiers may be applicable depending on the circumstances of the service.Consult the CPT manual and payer-specific guidelines.
Medical necessity for code 96416 is established when a patient requires prolonged intravenous chemotherapy infusion (more than 8 hours) due to their medical condition and the characteristics of the chemotherapy drug being administered. The use of a portable or implantable pump is necessary for the safe and effective delivery of the medication over an extended period. The physician's clinical judgment is critical in determining the medical necessity of the infusion based on the patient's condition.
The physician is responsible for initiating the infusion, which includes assessment, planning, ordering the medication, and supervising the administration of chemotherapy through a portable or implantable pump. The physician’s responsibility also includes monitoring the patient for adverse effects and making any necessary adjustments to the treatment plan.
- 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 services are considered primary to therapeutic, prophylactic, and diagnostic services, which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.
In simple words: This code covers the doctor starting a long-lasting (over 8 hours) IV chemotherapy treatment using a portable or implanted pump. The patient usually leaves the clinic after the pump is started.This code only applies to the initial setup of the pump; refills are billed separately.
This CPT code, 96416, reports the initiation of a prolonged intravenous chemotherapy infusion lasting more than eight hours, requiring the use of a portable or implantable pump.The code encompasses the physician's work in initiating the infusion, including assessment, planning, and supervision. It does not include subsequent refills or maintenance of the pump.
Example 1: A patient with metastatic breast cancer requires continuous infusion of docetaxel over 24 hours. The physician initiates the infusion using a portable pump. Code 96416 is reported for the initiation of the infusion., A patient with lymphoma needs a 12-hour infusion of rituximab. The physician starts the infusion via an implantable pump. Code 96416 is reported for initiating the infusion., A patient with chronic pain requires a 10-hour infusion of morphine sulfate through an implanted pump. The physician initializes the infusion. Code 96416 is reported for initiating the infusion.
Complete documentation should include:
** This code is specifically for the *initiation* of the infusion.Subsequent refills and maintenance of the pump are coded separately using codes 96521-96523.The duration of the infusion must exceed 8 hours to qualify for this code.Always verify payer-specific coverage and reimbursement policies.
- Revenue Code: P6C (Medicare Fee Schedule: MINOR PROCEDURES - OTHER)
- RVU: The relative value units (RVUs) for this code are subject to change and should be verified with the current Medicare Physician Fee Schedule.
- Global Days: This code does not have a defined global period. The global period will depend on the specific chemotherapy regimen and the subsequent procedures or services provided.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier does not apply to this code.
- Fee Schedule: Historical fee schedules are subject to change and should be obtained from relevant sources like the Medicare Physician Fee Schedule.
- Specialties:Oncology, Hematology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center