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 [...]