96413 is the first hour of a chemotherapy (or other highly complex drug or biologic) IV infusion and is always the code for the first infusion of the encounter, even when it ran less than 60 minutes. 96415 is “each additional hour” and is never reported alone; one unit is earned only when at least 31 minutes spill past the previous hour. So a 45-minute single-agent infusion is 96413 × 1 and nothing else; a 2-hour infusion is 96413 + 96415 × 1; 2 hours 31 minutes is 96413 + 96415 × 2. A second chemo drug infused sequentially is 96417, not a second 96413; a chemo infusion of 15 minutes or less is a push, 96409.
| Documented infusion time | Codes | Why |
|---|---|---|
| 15 minutes or less | 96409 | A push, not an infusion (CMS Pub. 100-04 Ch. 12 §30.5) |
| 16 to 90 minutes | 96413 × 1 | The initial hour; up to 30 extra minutes do not reach an additional hour |
| 91 to 150 minutes | 96413 + 96415 × 1 | 31+ minutes into the second hour |
| 151 to 210 minutes | 96413 + 96415 × 2 | 31+ minutes into the third hour |
| 211 to 270 minutes | 96413 + 96415 × 3 | and so on, one unit per additional hour with 31+ minutes in it |
The 31-minute threshold is the CPT time convention for “each additional hour” codes across the 96360-96549 family (the same rule governs 96366 and 96361), and CMS applies it as written. It is a documentation rule as much as a math rule: without charted start and stop times, there is no defensible basis to bill the infusion at all — 96413 needs its own supporting time, and 96415 needs a time that clears the 31-minute mark for each unit.
96413 describes the initial infusion “up to 1 hour”. It is not a code for “an hour” — it is the initial-service code for the encounter, and NCCI allows exactly one initial service per encounter (Ch. XI §N.1: “only one ‘initial’ service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites”). Every other administration that day hangs off it as an add-on: 96415 for more hours of the same drug, 96417 for a different chemo drug infused sequentially, 96411 for a chemo push, 96367 or 96368 for a non-chemo drug infused sequentially or concurrently, 96375 for a non-chemo push, 96361 for separately necessary hydration.
Whether a given biologic belongs in the 96413 family or the 96365 family is a separate question — it turns on CPT’s chemotherapy / highly complex biologic definition and on payer policy, not on the diagnosis — and the 96365 page walks through it drug by drug. Priced lines for the claims above, Medicare basis, are in the Code this visit tool on the chemo infusion page.
96413 × 1. It is an infusion (16+ minutes) and the only administration, so it is the initial service; 45 minutes does not reach the 91-minute mark that earns a 96415 unit. 96415 is an add-on and is never reported by itself.
190 minutes: the first 60 are 96413, minutes 61–120 are one 96415 unit, minutes 121–180 a second, and the final 10 minutes do not reach the 31 needed for a third. 96413 + 96415 × 2.
No. One initial code per encounter. The first (usually the longer) infusion is 96413 with 96415 for its additional hours; the second chemo drug infused sequentially is 96417, and 96415 also applies to its additional hours. Two initial codes require separate, medically necessary IV access sites and a PTP-associated modifier.
Pembrolizumab is an antineoplastic and is reported with the chemotherapy administration family. For non-oncologic biologics the family depends on whether the drug meets CPT’s highly complex biologic definition and on the payer’s policy; the 96365 / 96366 page lists the common drugs on each side.
Quoted passages are reproduced from the cited federal publications; everything else is our reading of them. The methodology by which we resolve source disagreements is described in the Methodology.