Oncology & Hematology Coding Alert

From J codes to Q, you’ll be coding properly with these quick tips.

Coding for chemotherapy involves much more than simply selecting the right infusion code — it also requires a coder to know the appropriate HCPCS and ICD-10 codes, creating more chances for errors and denied claims.

Check out the following three chemotherapy scenarios and read how you should code each example to ensure that you’re billing these services properly every time.

Is Incidental Hydration Reportable?

Scenario 1: The oncologist administers 170 mg of azacitidine intravenously to a patient with high grade myelodysplastic syndrome (MDS). The infusion runs continuously and is mixed in 500 ml of normal saline over 40 min. The nursing staff also documents that 30mg of azacitidine is wasted from the second single dose vial used.

Solution 1: You should report one unit of J9025 (Injection, azacitidine, 1 mg) for every milligram of azacytidine that you administer. The first step is to calculate the number of units that you should report. In this case, to bill the azacitidine administration, you’ll report J9025 x 200. The reason you should report 200 units instead of the 170 administered is because azacytidine (VIDAZA) is available in single-use, preservative-free vials of 100 mg. Thus, your physician would use two vials to administer 170 mg to the patient. The remaining 30 mg would be reported as wastage when supported and properly documented. According to Medicare policy, when drug wastage occurs from a single-use vial, you should report the total units of medication in the claim (i.e., you report both the dose administered as well as the dose wasted.)

Carriers vary on the appropriate filing of the total units. You may be required to report one line with the total amount (200 units) or two lines, one for the administered amount (170 units), and the second line for the wasted portion (30 units, with modifier JW (Drug amount discarded/not administered to any patient) attached. Thus, in the example cited above, you would typically report 170 units of J9025 on the first line, followed by 30 units of J9025-JW on the second line.

Do not report incidental hydration: You would not report code J7040 (Infusion, normal saline solution, sterile [500 ml=1 unit]). This is because your physician did not administer the saline for the purpose of hydration. Rather the fluid was used to administer the infusate containing the medication. Fluids used to administer drugs are considered as incidental hydration and are not be reported separately.

The appropriate procedure code is 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).  

Avoid J3490 Unless Absolutely Necessary

Scenario 2: A patient requires an oral anti-emesis medication with chemotherapy and the doctor gives her Thorazine. The practice reports J3490 (Unclassified drugs) since there is no listing for Thorazine in the J code series.

Solution 2: Because Chlorpromazine hydrochloride (brand name Thorazine) is an oral anti-emesis medication, it doesn’t fall under the J code series. The heading for the J codes reads, “Drugs administered other than oral method.”

Instead, you should report Q0161 (Chlorpromazine hydrochloride, 5 mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen) for oral chlorpromazine. This code applies to 5 mg dose of chlorpromazine over a 48-hour period.

Medicare requires that your physician indicate on the order that the beneficiary is receiving the oral anti-emetic drug(s) as full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapeutic regimen. The oral anti-emetic should be administered or prescribed by a physician for use immediately before, at, or within 48 hours after the time of administration of the chemotherapeutic agent.

The allowable period of covered therapy includes the date of service of the chemotherapy drug (day one counted as beginning at the time of treatment), plus a period not to exceed two additional calendar days, or a maximum period up to 48 hours.

You can report the oral anti-emetic drug(s) which are prescribed by your physician only on a per-chemotherapy-treatment basis. Link the visit to Z51.11 (Encounter for antineoplastic chemotherapy) as your primary diagnosis code so the payer knows that the patient presented for chemotherapy.

Watch your J3490 usage: As an aside, it’s important to only reserve J3490 for cases when there is no other code listed in HCPCS for the medication in question. Many payers have started cross-referencing J3490 with the NDC numbers billed on the claims to ensure that there aren’t more specific HCPCS codes to describe the medications.

“If a claim is submitted using an unlisted J-code (e.g., J3490) and a valid CPT^®/HCPCS code exists for the drug being administered, Blue Cross Blue Shield of Texas will deny the service line and request the provider to resubmit using the correct CPT^®/HCPCS code,” that payer says in a directive about J3490 misuse.

Therefore, be sure and scrutinize your drug supply claims so you don’t erroneously report J3490 when a more specific code exists.

Add-ons Aren’t Always Justified

Scenario 3: The physician administers decadron and aloxi as an intravenous piggy back infusion during an encounter for chemotherapy. The infusion lasts 19 minutes, and the practice reports +96368.

Solution 3: It is incorrect to submit code +96368 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; concurrent infusion [List separately in addition to code for primary procedure]) when drugs are combined in the same infusate bag.

You can best report the infusion of this single infusate with one unit of +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]). Note that +96367 is an add-on code and along with the initial chemotherapy administration code that describes the main reason for the encounter.