Oncology & Hematology Coding Alert

One of the first things you probably learned as a medical oncology coder is that -chemo admin- codes aren't just for chemo admin. The reality is that properly applying 96401-96549 on your claims requires digging through multiple layers of CPT definitions and then analyzing how your payers apply those definitions in their policies.

You-ll be on your way to claims success with this look at the CPT guidelines, two major Medicare players- interpretations, and what to do when your payer hasn't published its preferences.

CPT labels the chemotherapy administration code section (96401-96549) as -Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.-

And the guidelines for that section spell out that -chemotherapy- in 96401-96549 includes -other highly complex drugs or other highly complex biologic agents.-

The guidelines state that these codes apply to the following:

- non-radionuclide anti-neoplastic drugs

- anti-neoplastic agents for noncancer diagnoses (such as cyclophosphamide for autoimmune conditions)

- certain monoclonal antibody agents

- other biological response modifiers.

But what does this mean? Which drugs does this actually translate to in the real world?

First line of defense: Check your payer's policy for drug codes you should pair with

chemo admin codes.

For example, Noridian, a Medicare administrator in the West, offers guidelines explaining that the chemo codes are appropriate for only J9000-J9999 (Chemotherapy Drugs) and J1745 (Injection, infliximab, 10 mg), says Shelly Noll, CPC, with Rockwood Clinic in Spokane, Wash.

You can find the announcement online here: www.noridianmedicare.com/shared/partb/bulletins/2008/247_aug/Chemotherapy_Administration_Coding.htm.

The policy states that you should not use the chemotherapy codes with any other drug unless Noridian specifically adds it to that list, Noll says.

National Government Services (NGS), a Medicare contractor for many states throughout the U.S., has a longer list of acceptable drugs, which you can find online here: www.ngsmedicare.com/NGSMedicare/PartB/NewsandPublications/WhatsNew/PartBNews08/ngs_121108_coding.aspx.

Biological response modifiers: The policy indicates that if you supply the following biologic response modifiers (outside the J9xxx range), you should report the administration with the appropriate chemo admin code:

- J0215 -- Injection, alefacept, 0.5 mg

- J7516 -- Cyclosporine, parenteral, 250 mg

- J7525 -- Tacrolimus, parenteral, 5 mg

- Q3025 -- Injection, interferon beta 1-a, 11 mcg for intramuscular use.

Hormonal anti-neoplastics: Hormonal antineoplastics outside the J9xxx range that NGS considers an appropriate match to chemo admin codes are the following:

- J0128 -- Injection, aberelix, 10 mg

- J0970 -- Injection, estradiol valerate, up to 40 mg

- J1000 -- Injection, depo-estradiol cypionate, up to

5 mg- J1380 -- Injection, estradiol valerate, up to 10 mg

- J1390 -- Injection, estradiol valerate, up to 20 mg

- J1410 -- Injection, estrogen conjugated, per 25 mg

- J1435 -- Injection, estrone, per 1 mg

- J3315 -- Injection, triptorelin pamoate, 3.75 mg.

Monoclonal antibodies: The NGS policy also says to use the chemo admin codes for all monoclonal antibody administration.

If you aren't lucky enough to have a policy that spells out the exact drugs allowed, be sure you can support your decision.

For example, you can research the drug to learn its pharmacologic category, says Melanie D. Kramer, CPC, with Bozeman Deaconess Health Group patient financialservices in Montana.

Rituximab is in the -MAb- -- monoclonal antibody --family of drugs, as are bevacizumab and cetuximab, Kramer points out, noting that these all end in --mab.-

This approach can also be helpful if your payer has a policy that you should report all monoclonal antibodies with chemotherapy admin codes (as NGS states in the policy indicated above).

If this is the case, drug codes you may pair with chemo admin codes include (but aren't limited to):

- J0130 -- Injection, abciximab, 10 mg

- J0480 -- Injection, basiliximab, 20 mg

- J1745 -- Injection, infliximab, 10 mg

- J2323 -- Injection, natalizumab, 1 mg

- J2357 -- Injection, omalizumab, 5 mg

- J7513 -- Daclizumab, parenteral, 25 mg

- J9010 -- Injection, alemtuzumab, 10 mg

- J9035 -- Injection, bevacizumab, 10 mg

- J9055 -- Injection, cetuximab, 10 mg

- J9310 -- Injection, rituximab, 100 mg

- J9355 -- Injection, trastuzumab, 10 mg.

Before you decide to report a chemo admin code for a nonchemo drug, you and your clinical staff also should consider the CPT section notes stating that a service meriting these codes -requires physician work and/or clinical staff monitoring well beyond that of therapeutic drug agents (96360-96379) because the incidence of severe adverse patient reactions are typically greater.-

Examples CPT provides of greater work include frequent infusion rate changes, prolonged presence of the administering nurse to monitor the patient and make infusion adjustments, and frequent conferring with the physician.