Oncology & Hematology Coding Alert

See what the authorities say about billing concurrent saline -- CPT and HCPCS.

Six hours of infusions can include multiple reportable services and supplies for your claim. But spotting services and supplies you should not report may be the toughest part of your day.

Work your way through this scenario, offered by Jennifer Huntley, office manager for Kashif H. Ansari, MD, PA, in Baytown, Texas, to find important guidelines you can apply to your next infusion claim.

Initial Code Often Differs From First Service

You should choose your initial infusion code based on the main reason for the patients visit (chemotherapy in this case) rather than based solely on the order administered, according to CPT guidelines.

96409: Your initial code, therefore, should be for the 5FU intravenous push (IVP):96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

If you bear the cost of the 5FU, report one unit of J9190 (Injection, fluorouracil, 500 mg).

Identify Drug Type or RiskWrong + Code

Rule: CPT guidelines indicate that when you administer multiple infusions, you should report one initial code only, unless protocols require more than one IV site.

So assuming you have just one IV site, 96409 should be the only initial code you report for this encounter.

+96367: For our sample case, you should report +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion, up to 1 hour [List separately in addition to code for primary procedure]) three times.

One +96367 covers the first hour of Aloxi. If you furnish this antiemetic, report 10 units of J2469 (Injection,palonosetron HCl, 25 mcg) for 0.25 mg.

The second +96367 covers the first hour of leucovorin.If you report the 100 mg of this drug, which enhances 5FU, report two units of J0640 (Injection, leucovorin calcium, per 50 mg).

Remember: If your oncologist ordered Fusilev instead during the leucovorin shortage, Fusilev has a different HCPCS code: J0641 (Injection, levoleucovorin calcium, 0.5 mg). Certain carriers, such as Noridian and Palmetto GBA, announced temporary Fusilev coverage during the shortage, according to the American Society of Clinical Oncology.

The third +96367 is for the 33 minutes of dexamethasone (dex).

Note that if the dex and Phenergan ran in the same bag, one unit of +96367 covers administration of both.

+96368: If the dex and Phenergan were in separate bags, you should report +96368 (& concurrent infusion [List separately in addition to code for primary procedure]), too.

For the 6 mg of the steroid dex, report six units of J1100 (Injection, dexamethasone sodium phosphate, 1 mg),and report one unit of J2550 (Injection, promethazine HCl,up to 50 mg) to cover the 12.5 mg of the antihistamine Phenergan.

Watch the Clock for These Codes

+96366: You should report +96366 (& each additional hour [List separately in addition to code for primary procedure]) twice for this case. This covers the additional 31 minutes of Aloxi and additional 63 minutes of leucovorin.

Reason: CPT guidelines specify that you should report +96366 for infusion intervals of greater than 30 minutes beyond 1 hour increments.

+96375: For the Benadryl push, report one unit of+96375 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]).

One unit of J1200 (Injection diphenhydramine HCl, up to 50 mg) is appropriate if you report the Benadryl.

Solve the Concurrent Fluid Mystery

The patient receives two saline infusions. The first runs for 33 minutes together with the dex and Phenergan.But you should not code hydration admin for these 33 minutes.

Heres why: CPT guidelines state that when the provider uses fluids to administer the drug(s), the fluid administration is considered incidental hydration and is not separately reportable, points out Susan Kampa with Centra Care in Minnesota.

Also, the Correct Coding Initiative (CCI) manual,Chapter 11, states, If therapeutic fluid administration is medically necessary (e.g., correction of dehydration,prevention of nephrotoxicity) before or after transfusion or chemotherapy, it may be reported separately. Note the choice of before or after, indicating you should not report fluid admin during chemo.

Some payers spell this out for you. For example, WPS Medicare states, Separate payment is made for hydration therapy provided sequentially (but not concurrently) to the chemotherapy infusion, in its policy (www.wpsmedicare.com/part_b/policy/honc002.pdf).

Watch out: The first saline infusion does run alone for exactly 30 minutes, but CPT guidelines state you should not report hydration lasting 30 minutes or less.Plus, unless the doctor orders medically necessary hydration, the reality is that payers may consider this fluid admin included in the chemotherapy or other drug infusion. (Note how the CCI manual refers to medically necessary hydration and WPS refers to hydration therapy.)

The second saline infusion lasts 61 minutes and runs alone, but again, without an order for hydration, payers may include this admin in the chemotherapy or other drug infusion. Check the physicians prescription as well as the drug admin record to be sure the line wasnt simply kept running while the pharmacy mixed the leucovorin, for example.

HoldYour HCPCS Horses,Too

Chapter 11 of the CCI manual states, If the sole purpose of fluid administration (e.g., saline, D5W, etc.) is to maintain patency of an access device, the infusion is neither diagnostic nor therapeutic and should not be reported sepa-rately. Similarly, the fluid utilized to administer drug(s)/substance(s) is incidental hydration and should not be reported separately.

Result: You should not report HCPCS codes for the 150 mL normal saline (NS) or 250 mL D5W listed as diluents. For the saline that ran alone, oncology coding experts indicate that if the physician doesnt order the fluid as hydration, it is a supply, so you should not bill it separately.

Leave This CBC Collection OffYour Claim

You shouldnt report the port blood draw separately.

Reason: You should not claim 36591 (Collection of blood specimen from a completely implantable venous access device) on the same date as any other service, per CPT guidelines.