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 easily understood through mere five-digit CPT codes.

Modifier -53 was first implemented to use when a procedure is terminated after the induction of anesthesia or after the procedure begins, but is no longer an acceptable modifier for hospital reporting. Medicare allows use of modifier -53 for surgical and certain diagnostic procedures, but not to indicate discontinued radiology procedures. For terminated chemotherapy administration in a hospital, a new modifier, -74 (discontinued out-patient hospital/ambulatory surgery center procedure after administration of anesthesia), was implemented Jan. 1, 1999, and replaces modifier -53 for reporting discontinued services.

Must There Be a Payment Reduction?

Some Medicare carriers will reimburse without any payment reduction because they view the resources as consumed in essentially the same manner and to the same extent as they would have been had the procedure been completed, says Castillo. That includes the cost of the wasted chemotherapy drugs and the cost of administration. In some cases, however, payers will opt to reduce payment. It usually means theyll get about 50 percent, says Castillo. But they might get reimbursed the whole amount. They should contact the carrier to let them know what happened and discuss how it should be handled.

Laurie Lamar, RHIA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va., takes a different approach. Knowing that costs essentially are the same when comparing completed and discontinued chemotherapy administration, she advises not using modifier -53 and coding for the actual time of the chemotherapy administration and the total amount of the chemotherapy drug used, waste included. As a biller, why would I use a modifier if they are going to cut my reimbursement even though all the supplies and nursing time were used? Lamar says. If a practice happens to get audited, you show them the chart notes that show exactly what happened. In the absence of any other direction from HCFA, this is the best way.

Another reason Lamar is not keen on using modifier -53 or contacting the local Medicare carrier is that both actions may raise a red flag, prompting the payer to take a closer look and perhaps delay payment.

Documentation Is Key

Either way using modifier -53 or not documentation is vital to proving payment is justified. Chart notes should include details narrating the entire encounter. As with all chemotherapy administration, the start and stop times are mandatory. The chart notes also should include a description of the events leading up to the discontinuation of the chemotherapy, including a description of the patients reaction to the drug. Document the amount of chemotherapy drug that was prepared, used and wasted.

If you use modifier -53, provide documentation with the claim submission that describes the circumstances that required the discontinuation, Castillo says. If a practice submits its claim electronically, it should either use the remarks box to tell the payer to request records or submit a hard-copy claim.