Oncology & Hematology Coding Alert

Also, don’t overlook this blood transfusion advice.

Infusion services are always a source of coding confusion, which made Amy Lee Smith’s CPC, COC, CPMA, CPCO, AAPC Approved Instructor, MBA, FHFMA, CHFP, CIA, CRMA, CHIAP “Infusion Confusion” presentation at HEALTHCON Regional 2026 a valuable resource for both outpatient and inpatient infusion center coders. Smith’s presentation ended with seven audit tips — follow them to the letter, and you’ll be well on your way to clear, denial-free infusion coding.

Tip 1: Don’t Use More Than 1 ‘Initial’ Code Per Encounter

CPT^® infusion codes distinguish between initial and subsequent administrations, and CPT^® guidelines state you should only report one “initial” code per encounter “unless the protocol or patient condition requires that two separate IV [intravenous] sites must be utilized” because creating an initial IV site access requires more time and effort.

So, unless the provider opens up a second IV site during the same encounter, you should only use one of the following codes for the encounter:

• 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour)
• 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour)
• 96409 (Chemotherapy administration; intravenous, Push technique, single or initial substance/drug)
• 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug)

Remember: The term “initial” does not necessarily refer to the first service provided in the infusion encounter. In the outpatient setting, an initial service is the primary reason given for the visit; in the facility setting, it is the highest-ranking service in a hierarchy starting with chemotherapy infusions and descending through chemotherapy IV pushes, chemotherapy injections, therapeutic/prophylactic/diagnostic infusions, therapeutic IV pushes, therapeutic injections, and ending with hydration services.

Note: If the medical record does indicate the provider opened up a second IV access site, you can go ahead and report one of the “initial” codes with modifier 59 (Distinct procedural service) appended.

Tip 2: Don’t Use an Add-on Code Without a Primary Code

The infusion add-on codes are no different from any other add-on codes in the CPT^® code book, meaning they are subject to the CPT^® guideline that states “add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code.” So, you should not report:

• +96361 (… each additional hour...) without primary code 96360;
• +96366 (… each additional hour...), +96367 (... additional sequential infusion of a new drug/substance, up to 1 hour...), and/or +96368 (... concurrent infusion...) without primary code 96365;
• +96411 (... intravenous, push technique, each additional substance/drug... ) without primary code 96405 (Chemotherapy administration; intralesional, up to and including 7 lesions); or
• +96415 (... each additional hour...) and/or +96417 (... each additional sequential infusion (different substance/drug), up to 1 hour...) without primary code 96413.

Tip 3: Don’t Use an Administration Code Without a Medication Charge (and Vice Versa)

Simply put, any time you use a drug or chemotherapy administration code from 96365-96381 (Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration)) or 96401-96549 (Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration), you must report a HCPCS Level II J code to report the drug given to the patient.

The converse is also true: If you are reporting a drug using a HCPCS Level II J code, you must also report a code that reflects the drug’s administration.

Tip 4: Don’t Use the Blood Administration Code Without a Blood Product HCPCS Code (and Vice Versa)

Patients suffering from anemia or thrombocytopenia due to chemotherapy, or patients receiving treatment for blood cancers such as leukemia or multiple myeloma, will often need blood transfusions to restore red blood cells and platelets. When this happens, you’ll reach for a transfusion code, typically 36430 (Transfusion, blood or blood components).

But if you are supplying the blood product, you need to make sure your claim includes a HCPCS Level II code from P9010-P9100 (Blood and Blood Products With Associated Procedures) that reflects the kind of blood product administered during the transfusion.

And, just as you must report a drug administration code when you report a code for the drug administered, you must also report a code that reflects the means of transfusion.

Tip 5: Don’t Use the Blood Administration Code With a Revenue Code Other Than 0391

If you do bill 36430 in the hospital and/or facility setting, you must make sure it is accompanied by revenue code 0391 (Transfusion).

Tip 6: Don’t Code for Multiple Blood Transfusions per Encounter

Regardless of the number of units of blood or blood products transfused, you must only report 36430 once per transfusion.

Tip 7: Don’t Bill Venous Access Device Irrigation With any Other Service

Last, if you use 96523 (Irrigation of implanted venous access device for drug delivery systems) to report flushing or irrigating an implanted device that enables access to a patient’s veins for easy drug administration, be sure to heed the CPT^® instruction accompanying the code, which tells you not to report 96523 in conjunction with other services.

This is because the work involved in flushing the device is so minimal it is bundled into any other service performed on the same day. As Chapter 12 of the Medicare Claims Processing Manual states, “If there is a visit or other chemotherapy administration or nonchemotherapy injection or infusion service provided on the same day, payment for 96523 is included in the payment for the other service.”

Note: Amy Lee Smith was unable to attend HEALTHCON Regional 2026 in person, so Lee Williams gave the presentation her behalf. 

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC