Oncology & Hematology Coding Alert

Reporting 99363, 99364, or G0250 with these inpatient E/Ms will trigger a denial.

The Correct Coding Initiative (CCI) version 22.1 introduced many edits that could impact oncology and hematology practices. A whole large array of edits applies to observation, infusion codes, and other common procedure codes. Medicare doesn't pay separately for anticoagulant management codes 99363 and 99364, but that doesn't mean these codes can escape CCI edits. Listed here are some common codes you should never submit before you've checked for possible edits.

Don't Pair Anticoagulation and Observation Codes

On April 1, CCI enacted the following bundle: When the physician performs almost any hospital E/M for a patient, you cannot report any of the following codes in addition to the E/M:

• 99363, Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements)
• 99364, ... each subsequent 90 days of therapy (must include a minimum of 3 INR measurements) 

G0250, Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests.

These edits have a modifier indicator of 0, meaning you can never report the codes together for the same patient during the same encounter.

These are the E/M codes CCI says you may not report 99363, 99364, and G0250 with:

• 99217, Observation care discharge day management...
• 99218-99220, Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components ...
• 99221-99223, Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components ...
• 99224-99226, Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...
• 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...

Additional bundles prevent you from reporting anticoagulation services with critical care services coded with 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 99292 (... each additional 30 minutes [List separately in addition to code for primary service]).

Interpretation: "When in the hospital, the providers review and convey any lab results during the time spent with the patients at the bedside or on the patient floor. You would not report anticoagulation testing codes separately from a hospital E/M," explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at Acusis, LLC, in Pittsburgh, Pa.

From a CPT^® perspective, it's also worth noting that 99363 and 99364 each cover 90 days of outpatient therapy and G0250 covers four home tests with no more than one per week. The intent of these codes is not to cover review of testing performed on a hospital patient.

CCI Also Makes Sure You Don't Report INR at NF

CCI 22.1 also creates edits for 99363, 99364, and G0250 with nursing facility (NF) E/Ms:

• 99304-99306, Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components ...
• 99307-99310, Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...
• 99315-99316, Nursing facility discharge day management ...
• 99318, Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components...

These edits also have a modifier indicator of 0, meaning you can never report them for the same patient during the same encounter.

Interpretation: INR and anticoagulation management "is included during the time and work involved in those patient visits. The results are part of the chart and easily reviewable," Hauptman says.

Final tip: These edits are in line with CPT^® guidelines for 99363 and 99364: "These services are outpatient services only. When anticoagulation therapy is initiated or continued in the inpatient or observation setting, a new period begins after discharge and is reported with 99364. Do not report 99363-99364 with 99217-99239, 99291-99292, 99304-99318, 99471-99480 or other code(s) for physician review, interpretation, and patient management of home INR testing for a patient with mechanical heart valve(s)."

As mentioned earlier, Medicare does not pay separately for 99363 and 99364, giving them status B (bundled) on the Medicare Physician Fee Schedule. Code G0250 has status R, meaning coverage is restricted to certain unusual circumstances.

Check Before You Bill Any Procedure with IV Infusion

According to the CCI 22.1 edits, many procedure codes are considered a Column 1 code with each of these IV infusion procedures:

• +96361, Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)
• +96366, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
• +96367, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
• +96368, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure).

Example: For example, the infusion codes are column 2 codes for the procedures listed below, but a modifier is allowed in order to differentiate between the services provided:

• 57135, Excision of vaginal cyst or tumor 
• 38300, Drainage of lymph node abscess or lymphadenitis; simple 
• 58662, Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 
• 10060, Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.

Since the procedure code is in Column 1, you should only report the procedural code if performed during the same encounter as one of the four IV infusion codes mentioned above.

In almost all cases, there were already CCI edits bundling the corresponding base code into the procedure codes in Column 1. For instance, CCI already had a series of edits with 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) as the Column 2 code for the common procedures in Column 1. CCI 22.1 simply extends those edits to +96361, which is an add-on to 96360.

Modifier indicator: Each of these above mentioned edit pairs carries a modifier indicator of "1," meaning that you might be able to report both codes in an edit pair if you have sufficient documentation to support separate coding. If so, you should append an appropriate modifier (such as 59, Distinct procedural service) to the Column 2 code.