Oncology & Hematology Coding Alert

The Health Care Financing Administration (HCFA) does not have a written policy to guide oncologists regarding how to bill for partially used drugs and treatment that must end before chemotherapy is complete for example, because of an adverse patient reaction to the drug. The absence of such guidelines can lead Medicare carriers to draw different interpretations of how procedure codes should be applied and how costs should be reimbursed. Nevertheless, there are several options to consider as you bill for wasted drugs.

For example, a patient has just begun receiving chemotherapy in the office. The drug is mixed and the hours-long infusion has begun. The patient shows an adverse reaction to the drug, prompting the physician to stop treatment before even an hour has passed. The patient recovers, but the majority of the expensive chemotherapy drug has gone to waste. What can oncology practices do in cases such as this? Certainly, they shouldnt entertain the notion of absorbing the cost of the chemotherapy drug. Being paid for the drug, however, is a delicate situation.

Coding the Scenario

To understand how to code for such a situation, its important to start from the beginning of the patient encounter and look at all the appropriate codes. First, if a significant and separately identifiable evaluation and management (E/M) service was performed, depending on the level of service provided, oncology practices should include a code from the range of 99211 through 99215 (outpatient services, established patient).

Of course, codes 96400-96549 (chemotherapy administration) are used to indicate the mode of chemotherapy administration and the time it takes to deliver the drugs. In addition, J9000-J9999 (chemotherapy drugs) should be included on the claim. When administration was stopped, the code that best describes the type of chemotherapy administration and its intended length should be used along with modifier -53
(discontinued procedure) to show that chemotherapy administration was stopped to prevent harm to the patient, says Laurie Castillo, MA, CPC, president of the American Association of Procedural Coders Northern Virginia Chapter and president of Physician Coding and Compliance Consulting, both in Manassas, Va. Practices also should report the amount of chemotherapy drug that was used and the amount that was wasted as a result of the stopped procedure.

Use Modifier -53 for Extenuating Circumstances

According to the CPT manual, under certain extenuating circumstances the physician may terminate a surgical or diagnostic procedure. Extenuating circumstances are those that threaten the well being of the patient. When a surgical or diagnostic procedure is discontinued, the physician may report those circumstances by adding modifier -53 to the code that best describes the discontinued procedure. In general, practices should use modifiers to provide additional detail to help payers understand cases that are not straightforward or [...]