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Jurisdiction 11 Part B
Due to an adverse reaction to Rituximab, an infusion scheduled for over one hour was discontinued after 10 minutes. The physician conducted an examination and returned the patient to the care of the nurse for an additional hour of monitoring. Can we be reimbursed for the entire hour?

If we bill the administration as a push, or add CPT modifier 52 (reduced service) or 53 (discontinued service) to the infusion code, we will receive lower reimbursement. Aside from the charge for the physician’s examination, the same amount of the nurse's time and supplies were used as with a complete infusion.
Since the intent was for an infusion, CPT code 96413 (chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) would be more appropriate than billing as a push. The definition of CPT code 96413 states 'up to one hour;' therefore, the use of CPT modifier 52 or 53 would not be mandatory, especially with the additional time spent monitoring the patient after the infusion was stopped. Please note that documentation in the medical record of all time spent with the patient is critical. Use of CPT modifier 52 or 53 may result in reduced reimbursement, depending on the documentation submitted with the claim. If you do not agree with the amount of the reimbursement, you have the right to request a redetermination.


last updated on 06/10/2015
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