Oncology & Hematology Coding Alert

Don't expect payment if your patient's condition fails to meet specific criteria

If the oncologist provides both the diagnostic services described by 78804 and the therapeutic services described by 79403, you should be able to report the two codes together because they represent separate services. But your payer may require that you meet certain criteria before it will pay.

For example, to cover both 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; whole body, requiring two or more days imaging) and 79403 (Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion), Pennsylvania's HGSAdministrators, like many carriers, has very specific requirements for patients:

- relapsed or refractory low-grade, follicular, or transformed B-cell non-Hodgkin's lymphoma, including Rituximab refractory follicular non-Hodgkin's lymphoma

- less than or equal to 25 percent lymphoma marrow involvement

- a platelet count greater than 100,000 cells/mm

- a neutrophil count greater than 1,500 cells/mm

- no evidence of hypocellular bone marrow (less than or equal to 15 percent cellularity or marked reduction in bone marrow precursors)

- no history of failed stem cell collection.

In addition, you can use these ICD-9 codes to support medical necessity:

- 200.00-200.88--Malignant neoplasm of lymphatic and hematopoietic tissue; lymphosarcoma and reticulosarcoma

- 202.00-202.08--Other malignant neoplasms of lymphoid and histiocytic tissue; nodular lymphoma

- 202.80-202.88--Other malignant neoplasms of  lymphoid and histiocytic tissue; other lymphomas.

Watch out: Payers will deny your Zevalin therapy claims as not medically necessary if the physician provides the treatment under the following circumstances:

- when the physician provides multiple courses of treatment

- the physician administers the therapy as the initial treatment for patients with CD20 positive non-Hodgkin's lymphoma

- the patients have a platelet count less than 100,000 cells/mm

- the physician treats conditions other than relapsed or refractory low-grade, follicular, or transformed B-cell  non-Hodgkin's lymphoma.
 
Find the HGSAdministrators policy at www.hgsa.com/professionals/policy-notice/i57.html.