Oncology & Hematology Coding Alert

Chemotherapy sometimes has to be stopped such as when a patient has an adverse reaction during treatment. You can bill for the administration and the wasted drug as long as you provide the proper documentation. Some Medicare carriers will reimburse for the drug and administration without any payment reduction because they believe that the resources are used in the same manner and to the same extent as if the procedure had been completed. In some cases, however, payers may reduce administration payment by 50 percent.

Although the lack of Medicare guidelines leaves payment to the discretion of the carrier, it is important to know the correct coding procedures.

Chemotherapy is delivered in three ways: needle injection, IV infusion, and push technique. Injections and push techniques take minutes to administer, while infusions require more time.

If an adverse reaction follows a needle injection or push, administration codes such as 96408 (Chemotherapy administration, intravenous; push technique) should be reported because the administration of the drug was completed prior to the adverse reaction. In most cases the patient's adverse reaction will take place well after the chemotherapy is delivered.

Infusion codes are based on time. For example, 96410 (... infusion technique, up to one hour) should be billed if the treatment was cut short in the first hour, says Sharon Grimes, business office director for the West Clinic, an oncology practice in Memphis, Tenn.

It can be argued that simply starting the infusion falls under the definition of that procedure. "As long as you document what happened, you can bill 96410," she adds.

Imelda Lee, RHIA CTR, coding supervisor for the University Physicians Group in San Antonio, advocates a more conservative approach. In addition to reporting 96410, she recommends that you append modifier -52 (Reduced services) to alert payers that the procedure was not completed. It may seem that modifier -53 (Discontinued procedure) is more appropriate but, Lee says, modifier -53 should be reserved for surgical procedures and only be appended to 10040-69990.

After the first hour, oncology practices normally report +96412 (... infusion technique, one to eight hours, each additional hour [list separately in addition to code for primary procedure]) to describe the next hour and every hour subsequent to the first. If the chemotherapy wasn't stopped until after the first hour and if the second hour was not completed, oncology practices should report 96410 and +96412-52.

The appropriate chemotherapy code, J9000-J9999, should be included on the claim with the chemotherapy administration code. Practices should also report the amount of the drug that was used with the amount wasted. While there are guidelines on what to do with wasted drugs from single-use and multi-use vials, CMS does not have a written policy on drugs that are mixed and prepared to be wasted. For this reason, you should ask your local carriers for the proper coding.

You should be able to bill for the entire amount used or unused, Grimes says. "The wasted drug is billable because it was mixed for the individual patient, especially for that days visit," she adds.

Documentation is vital to prove that payment is justified. Chart notes should include details narrating the entire encounter. The notes should also include a description of the events leading up to the discontinuation of the chemotherapy, including a description of the patients reaction to the drug.

If you use modifier -52, documentation describing the circumstances requiring the discontinuation should be provided with the claim. If a practice submits its claim electronically, it should use the "Remarks" box to tell the payer to "request records." Submitting a hard-copy claim may be easier.