Oncology & Hematology Coding Alert

When a chemotherapy regimen is prescribed, it may require that multiple agents be given during the same visit. It is also common for the chemotherapy drugs to be given using different techniques. Coders in oncology practices must remember that the administration of multiple chemotherapy agents is separately payable by Medicare when the drugs are delivered using different routes, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.

For example, a patient with breast cancer (174.0-174.9) may receive one agent via intravenous push and others via intravenous infusion. Commonly, this is done using cyclophosphamide (J9070-J9097), doxorubicin (J9000), and 5-FU, (J9190). Some physicians administer both cyclophos-phamide and doxorubicin by IV infusion (e.g., 96410, Infusion technique, up to one hour, +96412, ... one to 8 hours, each additional hour [list separately in addition to code for primary procedure]), while the 5-FU is administered by IV push (e.g., 96408, Chemotherapy administration, intravenous push technique).

The CPT 2002 manual states that separate codes should be reported for each parenteral method of administration when chemotherapy is administered by different techniques. Therefore, you should bill both codes when both techniques are used. Apply modifier -59 (Distinct procedural service) to the lesser-paying chemotherapy administration code (96408) to ensure identification of these as separate procedures.

So the example given above should be coded 96410 (include +96412 if applicable) for the administration of cyclophosphamide and doxorubicin and 96408 for the administration of 5-FU; modifier -59 appended to 96408 shows payers that the IV push was a separate and distinct service from the infusion administration. Finally, code each of the chemotherapy drugs administered.

Medicare will pay for both a push and an infusion on the same day if different drugs are involved, but it will pay for only one administration by push technique (96408) per encounter regardless of how many drugs are administered. J codes for each drug should always be reported and linked to the corresponding technique code on the claim form.

While Medicare does not allow the push technique to be reported twice, some commercial payers may pay for it, Towle says. Check with commercial payers to ensure they are not applying Medicare coding practices.

In addition to chemotherapy agents, drugs that combat chemotherapy symptoms, such as anemia and nausea, will be a part of the coding mix. If it is simultaneous to chemotherapy, the administration of support drugs is bundled with chemotherapy administration codes.

Sequential administration of support-care drugs and chemotherapy, on the other hand, allows for billing the two procedures separately, says Lillie McAlister, CPC, president of Double Diamond Enterprises, a coding and consulting firm in Conroe, Texas. Some oncology practices, however, mistakenly bill for the administration of drugs like ondansetron (J2405), a nausea combatant, as part of the chemotherapy administration, which leads to lost revenue.

For example, an oncology practice treating a patient with lung cancer (162.3-162.9) who receives an intravenous dose of ondansetron prior to receiving an infusion of chemotherapy can separate supportive-care drugs and chemotherapy administration when billing. In addition to 96410, oncology practices can report 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour).

To prove that the supportive-care drugs and chemotherapy were provided sequentially, practices must ensure the patient record reflects the sequence of drug administration. The record should note the times the drugs were delivered. For instance, "Ondansetron 11 a.m.-11:45 a.m.; chemotherapy 12:30 p.m.-1:30 p.m."

Coding experts warn that vague notations in the patient record, such as "Ondansetron, chemotherapy from 11 a.m. to 1:30 p.m.," will cause payers to assume that the support-care drugs and chemotherapy were administered simultaneously. If a second infusion of the same supportive-care drug is administered after the chemotherapy, oncology practices should consolidate the time that supportive-care drugs are administered, rather than reporting 90780 twice. Use the add-on codes associated with 90780 if the administration time for the support drug totals more than two hours. So, both 90780 and +90781 (... each additional hour, up to eight hours [list separately in addition to code for primary procedure]) may be reported. Rather than considering supportive-care drugs administered before and after chemotherapy treatment as two distinct services, you should bill the cumulative time of both as one.

Oncology practices should also append modifier -59 to 90780 to indicate when codes 90780 and +90781 are provided sequentially rather than at the same time, Towle says.

Hydration therapy intravenous-infusion coding also causes confusion over whether or not to separate the service from chemotherapy administration. Like anti-emetogenic 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 chemotherapy IV infusion is allowed when these services are administered sequentially or as separate procedures.

Separate billing for saline or other intravenous solutions used for hydration is allowed. However, any saline or intravenous solution used for the administration of a chemotherapy drug is considered by Medicare 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 prior to the administration of Cisplatin (J9060), the saline can be submitted to Medicare for separate reimbursement. However, if the same patient was given a 50-ml bag of intravenous 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 intravenous infusion (90780 and/or +90781) and chemotherapy IV infusion (96410, +96412, or 96414) performed on the same day, sequentially or as a separate procedure, you must place modifier -59 on the hydration therapy intravenous-infusion codes.