Oncology & Hematology Coding Alert

Highlight these important takeaways and policy 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-CM 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 you’re billing these services properly every time.

Decide Whether to Report Incidental Hydration

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 minutes. The nursing staff also documents 30 mg of azacitidine is wasted from the second single dose vial (SDV) used. What codes should you report?

Answer: First off, you should report one unit of J9025 (Injection, azacitidine, 1 mg) for every milligram of azacitidine administered.

Takeaway: The first step is to calculate the number of units 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 azacitidine (VIDAZA) is available in single-use, preservative-free vials, or SDV 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.

Policy heads up: According to Medicare policy, when drug wastage occurs from a SDV, 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. Medicare does require submitting the claim on two lines, one for the administered amount and the second for the wasted amount of the SDV.

Do not report incidental hydration: You would not report the administration time of the normal saline code J7040 (Infusion, normal saline solution, sterile [500 ml=1 unit]).

Takeaway: 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.

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

Your claim should look like this:

• 96413 X1
• Depending on payer:​

o J9025 x 200 on one line or
o J9025 x 170 and J9025-JW x 30 on two lines.

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.

Answer: 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 a 5 mg dose of chlorpromazine over a 48-hour period.

Policy heads up: Medicare requires your physician indicate on the order 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) 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 the patient presented for chemotherapy.  Be sure to check for your specific local coverage determination policy (LCD) or for any other local coverage articles (LCA) for any additional or specific requirements that may apply.

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 more specific HCPCS codes describing the medications do not exist.

“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,” BCBS of Texas says in a directive about J3490 misuse.

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

Your claim should look like this:

• Q0161 linked to Z51.11

Add-ons Aren’t Always Justified

Scenario 3: The physician administers decadron and aloxi as an intravenous piggyback infusion in the same infusate bag during an encounter for chemotherapy. This piggyback infusion lasts a total of 19 minutes at time subsequent and not overlapping the chemotherapy was infusing.  Should the practice report +96368?

Answer: No, you should NOT 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]).  The drugs were combined in the same infusate bag, therefore each drug should be reported with their J codes, but the infusion was separate from the chemotherapy infusion.

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]). It is important to note +96367 is an add-on code, meaning you must report it along with the initial chemotherapy administration code capturing the main reason for the encounter.

Your claim should look like this:

• Initial chemotherapy administration code describing main reason for encounter
• +96367
• HCPCS codes for the supply of the drug(s).