Q&A: Interpreting the differences between CPT code 96416 and HCPCS code G0498

Q: Is CPT code 96416 (chemotherapy administration, IV infusion; initiation of prolonged chemotherapy infusion [more than 8 hours] requiring use of portable or implantable pump) the same as HCPCS code G0498 (chemotherapy administration, IV infusion; initiation of infusion in office/clinic setting using office/clinic pump/supplies with continuation of infusion in the community setting using a portable pump provided by office/clinic, includes follow up office/clinic visit at conclusion of infusion) but only G0498 is required by Medicare? Our facility has both charges set up and is trying to determine if it would be appropriate to set up G0498 as a Medicare override for 96416.

A: First, you want to check if your other payers are accepting G0498. That code describes more than what CPT code 96416 does. HCPCS code G0498 is for a portable pump and not the implantable pump. Code 96416 is still a valid code for Medicare purposes as well, so you'd want to check with your other payers about whether they're also accepting G0498, which is inclusive of additional information.

Many providers have asked a number of questions about G0498 to Medicare early in the year and they kept saying, "Read the long descriptor of this code, and that is really where you're going to understand how this code is really different."

When I look at the long descriptor of G0498, it's about setting up this portable pump where the pump is being given, which you see where it says “using a portable pump that's provided,” and the code includes the follow up. Your other payers may accept this code. If they are not accepting this code, then you would still use 96416 and you would report your E/M code separately. But if they are following Medicare and they're accepting this, then remember this code is inclusive of essentially those three things.

Editor’s Note: Jugna Shah, MPH, president and founder of Nimitt Consulting, answered this question during the HCPro webinar, “JustCoding’s Virtual Workshop: Injections and Infusions.”

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