Oncology & Hematology Coding Alert

Watch out: The 'T' in TC may not stand for what you think. In recognition of National Women's Health Week (May 9-15), give your breast cancer chemotherapy coding a check-up. Below are details on coding several common regimens that include chemotherapy drug cyclophosphamide, and some breast neoplasm ICD-9 essentials to boot. Keep in mind: In the world of chemotherapy drug coding, you should "never assume anything. You could be wrong," warns Shelly Noll, CPC, who works in oncology, hematology, and radiation for Rockwood Clinic in Spokane, Wash. If you can't tell by the notes what a drug is, an auditor can't either, says Noll. That could set you up for audit trouble, so you want to be sure the documentation and coding are first rate. Assess Lengthy Cyclophosphamide Code Range If you turn to the table of drugs in your HCPCS manual, you'll see a large range of coding options for intravenous cyclophosphamide (sold as Cytoxan or Neosar). All the codes from J9070 (Cyclophosphamide, 100 mg) to J9097 (Cyclophosphamide, lyophilized, 2.0 gram) describe cyclophosphamide, says Noll. To choose the proper code, you must have documentation of the exact drug, stresses Noll. "Was it cyclophosphamide or cyclophosphamide lyophilized? Both are cyclophosphamide," but you use different drug codes for them, Noll explains. Term tip: Lyophilized means freeze-dried. Selecting the proper code also depends on the amount administered, Noll says. The cyclophosphamide code definitions differ based on the amount of drug, as this table shows: Example: Suppose your documentation shows administration of 400 mg of nonlyophilized cyclophosphamide. You should report two units of J9080 (Cyclophosphamide, 200 mg). Start With AC and J9000 AC: One regimen you may see the oncologist prescribe fairly often is the AC (or CA) regimen. The letters stand for cyclophosphamide and another chemotherapy drug, Adriamycin (doxorubicin). When the time arrives to code the "A" (Adriamycin/ doxorubicin) part of the CA regimen, you'll have fewer options to ponder than for the cyclophosphamide. HCPCS shows J9000 (Injection, doxorubicin hydrochloride, 10 mg) and J9001 (Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg) for doxorubicin, Noll says. The key to choosing between them is determining whether the provider administered the lipid formulation,she adds. The lipid formulation (J9001, sold as Doxil) is intended for ovarian cancer, according to the manufacturer. So J9000 is more likely to be the correct choice. But cancer treatments are constantly developing, so always base your code choice on the services and supplies documented. Focus on J9190 for 5-FU Regimens Several breast cancer regimens combine cyclophosphamide and chemotherapy drug 5-fluorouracil (5-FU), sold under the name Adrucil. You should assign J9190 (Injection, fluorouracil, 500 mg) for 5-FU, Noll says. CAF/FAC: Both the CAF and FAC regimens involve Cytoxan (cyclophosphamide) and Adriamycin (doxorubicin), like the CA regimen discussed above, but the regimens add 5-FU to the cocktail. CAF and FAC may differ in doses and frequency of administration. CMF: Another alternative you might see is CMF: cyclophosphamide, methotrexate, and 5-FU. For chemotherapy drug methotrexate, non-oral, choose between J9250 (Methotrexate sodium, 5 mg) and J9260 (Methotrexate sodium, 50 mg), based on the dose administered. FEC/FECD: Finally, for the FEC (or CEF) variation, the nurse administers epirubicin at the same encounter as 5- FU and cyclophosphamide. Your practice should report the chemotherapy drug epirubicin, sold as Ellence, using J9178 (Injection, epirubicin HCL, 2 mg). The oncologist may also choose to follow the FEC cycles with cycles of docetaxel therapy. You may see this regimen called FECD. For the docetaxel (Taxotere) report J9171 (Injection, docetaxel, 1 mg). Be sure to watch your units because HCPCS revised your docetaxel coding choice in 2010. You reported the previous code (J9170, Injection, docetaxel, 20 mg) once for every 20 mg. You report the new code, J9171, once for every 1 mg. Take Time to ID 'T' in TC AC+T/ACT: You may see docetaxel (Taxotere) prescribed in breast cancer regimens other than FECD. For some patients, the oncologist may add Taxotere to the AC regimen. AC+T usually refers to an AC cycle followed by a Taxotere cycle. TAC or ACT instead tends to mean thenurse administers the three drugs at the same encounter. TC: As another alternative, for the TC regimen, the oncologist may prescribe Taxotere and cyclophosphamide, without Adriamycin. Name check: The "T" may also refer to Taxol. Assign J9265 (Injection, paclitaxel, 30 mg) for this drug, which is also sold under the names Onxol and Nov-Onxol. Any time you aren't sure about a drug, "verify the drug with the nursing staff or a pharmacy tech, if necessary," says Noll. Complete the Coding Puzzle: ICD-9+CPT All of the drugs discussed above are chemotherapy drugs, and therefore you should pair them with chemotherapy administration codes 96401-96549. For the diagnosis, keep these codes in mind, but base your choice on the documentation: 174.x -- Malignant neoplasm of female breast 233.0 -- Carcinoma in situ of breast. "Malignant neoplasms are cancerous, and may be noninvasive (in situ), or invasive," explains R.M. Stainton Jr., MD, president of Doctors' Anatomic Pathology Services in Jonesboro, Ark. ICD-9 further subdivides invasive cancers as "primary," meaning that the cancer arises from surrounding cells, or "secondary," meaning that the cancer metastasized (spread) from a primarymalignancy located elsewhere in the body. Secondary malignant neoplasm of breast (198.81,Secondary malignant neoplasm of other specified sites;breast) means the primary tumor is somewhere else and metastasized to the breast. If instead the treatment is directed at cancer that metastasized from the breast, code for that location, such as 196.3 (Secondary and unspecified malignant neoplasm of lymph nodes; Lymph nodes of axilla and upper limb).