Oncology & Hematology Coding Alert

Test yourself by choosing the proper codes and units for this encounter.

Finding the proper codes -- even for well-documented visits -- can require some detective work. Take a look at the sample scenario and make your choices for the appropriate ICD-9-CM, HCPCS, and CPT® codes.

Scenario: Documentation shows the patient presents for her first day of chemotherapy, aimed at treating stage III epithelial ovarian cancer (primary).

The tracking form for the patient shows the following infusions:

• 0817-0833, dexamethasone sodium phosphate, 20 mg IV, in 50 mL NS
• 0834-0854, diphenhydramine, 50 mg IV, with ranitidine, 50 mg IV, in 50 mL NS
• 0924-1226, paclitaxel, 233.55 mg IV, in 500 mL NS.

ICD-9-CM: Take It 1 Code at a Time

The first-listed diagnosis code should be V58.11 (Encounter for antineoplastic chemotherapy). According to ICD-9-CM official guidelines, V58.11 must be the primary code when the visit is solely for chemotherapy (guidelines are available at www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm).

Next: You should report the code for the neoplasm being treated. In this case, you should use 183.0 (Malignant neoplasm of ovary) to describe the stage III epithelial ovarian cancer, says Melanie Witt, RN, COBGC, MA, an independent coding consultant in Guadalupita, N.M.

You can tell from "stage III" that the neoplasm is malignant, Witt notes. Under the system used for staging, stage III ovarian cancer means the cancer is in one or both ovaries and has spread to the abdominal lining, the lymph nodes, or both.

Knowing that the treated neoplasm is primary is also important, as you would use 198.6 (Secondary malignant neoplasm of ovary) if the neoplasm were a secondary malignancy, Witt says.

Don't miss: A note with 183.0 says to "use additional code to identify any functional activity." The notes for the ICD-9-CM neoplasm chapter tell you that "an additional code from Chapter 3 ["240-279: Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders"] may be used to identify such functional activity associated with any neoplasm."

Another possibility for ovarian cancer "might be an elevated CA-125 prior to surgery, so you can add this code as a secondary diagnosis," Witt says. The appropriate code would be 795.82 (Elevated cancer antigen 125 [CA 125]).

HCPCS: Bring Out the Units Calculator

Before you can choose the appropriate infusion codes, you'll need to identify the specific agents administered. The nature of the agent will affect your CPT® infusion code choice.

The appropriate code for chemotherapy drug paclitaxel is J9265 (Injection, paclitaxel, 30 mg). To determine the number of units, you should divide the amount administered (233.55 mg) by the amount in the code definition (30 mg). Do the math, and the answer is 7.785. Because Medicare allows you to round up to find your final number for units, the correct number of units is 8.

Note that if the record shows the drug is instead paclitaxel protein-bound, you should report J9264 (Injection, paclitaxel protein-bound particles, 1 mg). You would report this code per milligram (for instance, 234 units for 234 mg).

For the dexamethasone (a steroid), you should report J1100 (Injection, dexamethasone sodium phosphate, 1 mg). You report the code per milligram, so you should report 20 units to represent the 20 mg administered.

The appropriate code for the antihistamine diphenhydramine is J1200 (Injection, diphenhydramine HCl, up to 50 mg). One unit will report the 50 mg administered.

Use J2780 (Injection, ranitidine hydrochloride, 25 mg) for the ranitidine, a histamine H2-receptor antagonist. You'll need 2 units for the 50 mg the patient received.

Tip: The documentation notes the amount of normal saline (NS) used in the infusions. But CPT® guidelines state, "Fluid used to administer the drug(s) is incidental hydration and is not separately payable," noted Lynn M. Anderanin, CPC, CPC-I, COSC, in her presentation, "Don't Get Stuck with Rejected Claims for Infusion Therapy Services" (www.audioeducator.com).  

CPT®: Start With the 'Initial' Code

To choose your infusion codes, you'll need to understand and apply CPT® guidelines related to these codes.

One key rule is that when you're reporting multiple infusions, you should report only one "initial" service. (There is an exception if the protocol requires two separate IV sites.) Physician coders should identify the primary reason for the encounter and use the initial code for that service.

For the sample case, the patient presents for chemotherapy. That makes the paclitaxel infusion your primary service. The infusion lasted three hours and two minutes. For the first hour, you should report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should report +96415 (... each additional hour [List separately in addition to code for primary procedure]) with a quantity of 2 to represent the next two hours. You should not report the final two minutes of the infusion separately. To report an "Additional hour" code, documentation must show an interval more than 30 minutes beyond an hour, and the final two minutes in this case don't meet that requirement.

Next: You also need to report the dexamethasone, diphenhydramine, and ranitidine infusions.

"The administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy administration," Anderanin said.

So for these infusions, you'll use the "Therapeutic, prophylactic, or diagnostic injection" sequential codes. Although these codes are in a different section than the chemotherapy infusion codes, you should not report a non-chemotherapy initial code if a chemotherapy admin is your initial service.

To report the 16-minute dexamethasone infusion, you should use +96367 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; additional sequential infusion, up to 1 hour [List separately in addition to code for primary procedure]). Note that this 16-minute service is an infusion and not a push. Per CPT®, the definition of a push is "(a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less." Because this service was recorded as 16 minutes, you should report it as an infusion.

The 20-minute administration of the diphenhydramine and ranitidine mixture also does not qualify as a push, and you should report the admin with another unit of +96367. (Note: Some coders report that their payers request +96367, +96367-59, Distinct procedural service, instead of 2 units of +96367. If this is your payer's preference, be sure to get the instructions in writing so you can support your coding if necessary.)

You should report only one additional unit for the mixture admin because the drugs are mixed in a single bag. The mixture in a single bag also means you should not use concurrent code +96368 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; concurrent infusion [List separately in addition to code for primary procedure]). To report that code, providers must administer drugs in distinct bags at the same time.

Final coding: For this case, your final coding should include:

ICD-9-CM: V58.11, 183.0 (you may use additional codes to identify functional activity)

HCPCS: J9265 (8 units), J1100 (20 units), J1200 (1 unit), J2780 (2 units)

CPT®: 96413, +96415 (2 units), +96367 (2 units).