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MDS Coding:

To Code Or Not To Code Chemo: Make The Right Choice Every Time

Published on Thu Sep 02, 2004

Hint: Don't try to code by the drug classification alone or its consolidated billing status.

If you're confused about coding chemo, you're not alone.

Coding chemotherapy and related services is tricky business. One wrong turn can lead down a trail to medical review - another one will rob the facility of RUG payment for a cancer patient with complex nursing needs.

The first step out of the coding maze: Ask whether the resident is receiving a medication that counts as chemotherapy when coding Section P1aa. "You only code a resident as receiving chemotherapy in Section P1aa if he's receiving a drug classified as an [anticancer] chemotherapy agent administered for an oncology condition," instructs Patricia Boyer, RN, MSM, a consultant with BDO/Heritage Group in Milwaukee.

"For example, Megace would meet the first condition but not the second one if the facility were giving it to a resident as an appetite stimulant," she says. "The same is true for methotrexate administered for an autoimmune condition.

"Tamoxifen does qualify as both and can be coded in P1aa when given to prevent a recurrence of breast cancer, but it would not count it were being administered to a woman at high risk for breast cancer who had never been diagnosed with the condition," Boyer adds.

Tip: Code cancer chemotherapy administered by any route, including oral.

Know the RUG Calculation

Accurate coding of P1aa is essential, because administration of chemotherapy qualifies a resident for the Clinically Complex category, notes Lynn Gerard, RN, director of nursing at Guardian Angels Care Center in Elk River, MN. "Since the lookback period for Section P is 14 days, chemotherapy administered in the hospital can actually enhance both your 5-day and 14-day RUG scores."

Coding tip: Qualifying for Clinically Complex also counts as one point to put the resident in a [higher] Extensive Services category if he already qualifies for it. Here's how it works: If the resident qualifies for Extensive Services, then look to see if he has any of these five conditions (for a count of 0 to 5), instructs Nathan Lake, RN, an MDS software developer and clinical expert in Seattle. The conditions are:

  • K5a (parenteral/IV )

  • P1ac (IV medication)

  • Qualifies for Special Care

  • Qualifies for Clinically Complex

  • Qualifies for impaired cognition

    If the resident otherwise qualifies for Extensive Services, the tally is used as follows.

    4 or 5 = SE3

    2 or 3 = SE2

    0 or 1 = SE1

    Don't Code These Services Administered During Chemo

    You always code the resident's cancer chemotherapy in Section P, regardless of the administration route or whether the resident receives it offsite or in your facility. But don't code IVs, IV meds or blood transfusions administered as part of a chemotherapy session, which will affect RUG placement.

    "IVs, IV meds and blood transfusions provided during chemotherapy are not coded under respective items K5a (parenteral/IV), P1ac (IV medication) and P1ak (transfusions)," according to the August 2004 update to the RAI user's manual. Avoid this mistake: "Even though a chemotherapy agent is excluded from consolidated billing, you can't code a blood transfusion, IVs or IV meds administered during the chemotherapy session," emphasizes Cindy MacQuarrie, RN, MN, with BKD Inc. in Kansas City, MO.

    Chemo Over? Start Coding

    How do you code instances where the resident returns to the facility with an IV after a chemotherapy session? To answer that question, Boyer advises facilities to ask this question: "'Has the IV or IV medication become part of the resident's plan of care following the chemotherapy?' If so, then you can count the IV or IV med on the MDS," she says. Or if a resident requires a blood transfusion due to low platelets, etc., when he returns to the facility, code that transfusion at P1ak, experts advise.

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