Oncology & Hematology Coding Alert

Although there is an obvious difference between chemotherapy infusion and supportive-care drugs, some oncology practices are using chemotherapy administration codes incorrectly to get paid for nonchemotherapy drugs that are administered by injection. Doing so may garner higher payments, but more often will lead to denials or audits.

Instead of using 96410 (infusion technique, up to one hour) for administration of nonchemotherapeutic drugs, oncology billers should use 90780 (IV infusion therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour).

Unbundle Supportive-care Drugs, Chemotherapy Administration

Dont waste billing opportunities by automatically bundling supportive-care drugs with chemotherapy administration, says Laurie Lamar, RRA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va. With proper documentation, practices can bill chemotherapy and the administration of supportive-care drugs as two distinct services.

Because of the host of drugs that accompany chemotherapy, billers often try to expedite the process by including supportive-care drugs such as ondansetron, a nausea combatant, with chemotherapy administration even if the chemotherapy and ondansetron are administered during a different time period.

For example, a breast cancer patient receives an IV dose of ondansetron (J2405) just before receiving a chemotherapy infusion. The oncology practice can separate the supportive-care drug, in this case the ondansetron, and the chemotherapy administration for billing purposes. In addition to using 96400-96549 for chemotherapy administration, oncology practices also can bill 90780.

On the other hand, if the antiemetic drug and chemotherapy are administered simultaneously, the practice must bundle the antinausea medication with chemotherapy administration, Lamar says. Rules for Medicare call for supportive-care drugs to be billed separately if they are administered sequentially to chemotherapy treatment, she says.

Carefully Document Sequence of Drug Administration

Oncology practices need to document the sequence of drug administration carefully, says Daniel Johnson, director of Health Care Consultants of America, a coding consulting firm in Augusta, Ga., which works with oncology practices. [Supportive-care] drugs should be coded separately whenever possible, he says.

To reimburse these medications, payers require them to be indicated for use with chemotherapy agents. In the case of antinausea medication, the chemotherapy drug must be listed as an agent that causes adverse reactions of moderate to severe vomiting.

To prove the supportive-care drugs and chemotherapy were provided sequentially, Lamar says, practices must ensure the patient record reflects the sequence of drugs. The record should note the times the drugs were delivered, as in the following example:

Ondansetron 11 a.m. 11:45 a.m.
Chemotherapy 12:30 p.m. 1:30 p.m.
Ondansetron 2 p.m. 2:30 p.m.

Lamar warns against using vague notations, such as: ondansetron, chemotherapy from 11 a.m. to 2:30 p.m.

Billing for emetogenic therapy with these agents also must include the chemotherapy ICD-9 code (V58.1) and the corresponding code for the cancer being treated (140-208.9). Code V58.1 and the ICD-9 cancer code also serve as documentation for medical necessity and should be submitted with each claim.

Lamar also advises practices to consolidate the time supportive-care drugs are administered in conjunction with chemotherapy treatment. Instead of treating the administration of supportive-care drugs given before and after chemotherapy treatment as two distinct services, the cumulative time of both should be billed as one. If the time exceeds one hour, the claim should include both 90780 and 90781 (each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]).

Tip: Physicians should use modifier -59 (distinct procedural service) when one drug is given separately from the second. If both medications are administered at the same time (i.e., in the same IV solution), then -59 cannot be used.

Clearing the Confusion of Hydration Therapy

Hydration therapy IV infusion (90780 and/or 90781) also creates some confusion regarding whether to separate the service from chemotherapy administration, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C.

Like antiemetogenic drugs, hydration therapy should be bundled into the payment for chemotherapy IV infusion (96410, 96412 or 96414) when administered simultaneously. Separate payment for hydration therapy and the IV infusion is allowed when these services are administered sequentially or as separate procedures. Separate payment also is allowed for saline or other IV solutions used for hydration with or without chemotherapy. Medicare, however, considers any saline or IV solution used for the administration of chemotherapy drugs to be included in the reimbursement for the chemotherapy IV infusion.

For example, if a patient is given hydration with a 0.9 percent sodium chloride solution before the administration of Cisplatin (J9060), the saline solution can be submitted to Medicare for reimbursement. If the same patient, however, is given a 50-ml bag of IV solution that is used to mix the drug, the solution is considered to be included in the reimbursement for the chemotherapy IV infusion.

When billing for hydration therapy IV infusion and chemotherapy IV infusion performed on the same day either sequentially or as a separate procedure, modifier -59 must be placed on the hydration therapy codes.

Coding Oral Supportive-care Drugs

Callaway-Stradley also warns billing staff to be careful in coding orally administered supportive-care drugs, such as antiemetics (Q0163-Q0181). These can be tricky because they are self-administered drugs, for which Medicare generally does not pay. Medicare does make an exception, however, when oral antiemetics are full therapeutic replacements for those administered by IV.

Although these drugs can be billed separately from chemotherapy administration if the physician dispenses the pills in the office and later sends the patient home with them, the physician cannot bill for their administration because 90780 is for IV therapy only.