Oncology & Hematology Coding Alert

Revealed: Why using modifier -59 can mean the difference between payment and denial

With your chemotherapy drug reimbursement taking a hit in 2005, you don't want simple coding mistakes to lead to even more lost revenue for chemotherapy administration. To get what you deserve, you should know how to report same-day pushes and infusions, and therapeutic infusion and injections.

1. Use J Codes, Modifiers to Support Multiple 96408 Charges

Suppose the oncologist or nurse provides multiple "push" chemotherapy treatments to the same Medicare patient on the same day. As of Jan. 1, 2004, you can report 96408 (Chemotherapy administration, intravenous; push technique) for each drug the physician or staff administered, says Linda Zimmerman, a coding specialist with IMA Inc., a Bloomington, Ind.-based multi-specialty practice that includes oncologists.

"This does not mean multiple chemotherapy administrations are payable for a single chemotherapy injection," Zimmerman says. "What this means is that you can report more than one administration on a day if multiple drugs are administered."

For example, the nurse uses the push technique to provide chemotherapy drugs Cisplatin (J9062), Dacarbazine (J9130) and Fluorouracil (J9190). You should report 96408 x 3 in addition to the three drug codes, says Kelly Reibman, CPC, a billing representative for an oncology practice in Easton, Pa.

You should also make sure the medical documentation shows that each drug required additional procedure time, preparation, supplies and patient education, according to the American Society of Clinical Oncology guidelines. This way, you support your case for reporting multiple pushes.

Another way: Some Medicare carriers require that you attach a modifier to one or more of the chemo pushes. For instance, if you report 96408 three times in Illinois, Medicare instructs offices to attach modifier -76 (Repeat procedure by same physician) to the second and third charges (96408-76), says Sue Coffee, office administrator at Central Illinois Hematology Oncology Center in Springfield, Ill.

When billing Indiana Medicare, you should attach modifier -59 (Distinct procedural service) to the second and third "push" administration encounters, Zimmerman says. On the other hand, in Pennsylvania, the local Medicare carrier doesn't require any modifiers, Reibman says.

The bottom line: You should only report 96408 multiple times when the oncologist or nurse administers multiple drugs. But check with your local carrier before you attach any modifiers.

2. Know Which Infusion Codes Are Bundled

Reporting multiple chemotherapy infusions (96410-96414) can be trickier than multiple push administrations because the National Correct Coding Initiative (NCCI) edits consider the infusion codes mutually exclusive.

"For a given anti-cancer agent, only one intravenous route (push or infusion) is appropriate at a given chemotherapy session," Zimmerman says. "But Medicare and commercial payers recognize that frequently combination chemotherapy is provided by different routes at the same session."

Tip: You can bypass this edit if you know which code you should attach modifier -59 to, and if the documentation shows that the physician provided the chemo through different routes and by different techniques.

For example, the oncologist provides three hours of chemotherapy infusion in the office. Then, the physician initiates a prolonged infusion of an implantable pump, which the patient will take home. To code the first hour of chemo, assign 96410 (... infusion technique, up to one hour), and for the other two hours, use +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]). Report the pump initiation as 96414-59 (... infusion technique, initiation of prolonged infusion [more than 8 hours], requiring the use of a portable or implantable pump) to show that this service was distinct from the two infusions.

Also, remember that you don't need to attach modifier -59 to 96412 because this is an add-on code, which you can assign only with 96410.

3. Tie Codes for Benign Conditions to 90780-90781

You may already know how to report therapeutic infusion and injection codes (90780-90788) when the physician or nurse administers non-chemotherapy drugs for hydration or to treat chemo-induced side effects.

But many oncology coders don't know that they can capture payment for 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) when the physician uses chemotherapy to treat benign conditions such as multiple sclerosis (340), Coffee says.

The lowdown: Medicare pays for chemotherapy administration codes (96400-96549) only if the oncologist gives the patient a cancer diagnosis.

Therefore, you can't assign these codes for treatment of a disease like multiple sclerosis, even if the physician uses chemotherapy drugs.

Solution: Report 90780 and 90781 (for more than one hour) instead of a chemotherapy code, and tie the appropriate diagnosis (for example, 340) to 90780. Remember that 90781 is an add-on code, so you don't need to link it to an ICD-9 code.