Oncology & Hematology Coding Alert

Pinpoint the troublemaker that’s causing hydration coding frustration.

Oncology coders around the country are facing Medicare denials when they report subsequent hydration code +96361 in addition to any primary code other than 96360. Here’s what’s causing these denials, why they’re inappropriate, and when you can expect to see CMS fix the problem.

Get an Overview of the Cause and the Cure

In brief, the hydration denials stem from a Correct Coding Initiative (CCI) rule for add-on code/primary code pairings. The rule erroneously says 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) is the only primary code allowed for +96361 (… each additional hour [List separately in addition to code for primary procedure]). As a result, Medicare denies +96361 unless 96360 is also on the claim.

The CCI rule conflicts with CPT® guidelines, which state you should report +96361 for hydration administered as a secondary or subsequent service for 96360 or any of these other initial services administered through the same IV access:

96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug

96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug.

CMS has stated it will correct the rule starting July 1, 2013, according to Bobbi Buell, MBA, of onPoint Oncology, in her May 2013 E-Reimbursement Newsletter.

Local MACs are confirming that they will be implementing the correction as scheduled. For instance, “When we contacted the payer, in this case [J9 MAC] FCSO, we were told that the edit would be fixed on July 1,” says Jana Palmer, CHONC, coder with Coastal Oncology of Ormond Beach, Fla.

Go In Depth: Identify the Culprit Transmittal

Taking time to understand why the problem occurred will help you be on guard for similar problems in the future. It starts with CMS Transmittal 2636, CR 7501, dated Jan. 16, 2013, and effective April 1, 2013, says Gina Nuske, CPC, practice administrator at Oncology & Hematology Associates in Canton, Ohio.

The Transmittal divides add-on codes among three tables based on whether CPT® provides (I) an exhaustive list of primary codes, (II) no defined primary codes, or (III) a partial list of primary codes for a given add-on code.

Keep in mind: Identifying proper add-on/primary code pairings is important to accurate coding because an add-on code reports a service that is always performed together with another primary service. “An add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner,” states the Transmittal.

(Note that critical care services are an exception, as explained in “3 Tables Affect Medicare Reimbursement for Your Add-On Code Claims” on page 51.)

However, as the current hydration denials reveal, add-on/primary code pairings can cause problems when a payer’s pairings don’t match clinical practice or other coding rules.

Compare Transmittal to Hydration Coding Guidelines

The source of the recent denials is the Transmittal’s Table I, which incorrectly lists 96360 as the only possible primary code for +96361. This rule triggers an inappropriate denial if you report a non-hydration infusion, injection, or push as the initial service.

For example: Suppose a patient presents for a cyclophosphamide infusion. The nurse first administers an hour of therapeutic hydration ordered by the physician. Then, the patient has a 55-minute infusion of cyclophosphamide.

You should report only one “initial” service code “unless protocol requires that two separate IV sites must be used,” CPT® guidelines state. The exact same rule is in Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.5.E, Buell noted. And CCI’s own manual includes this rule in Chapter XI, Section N (see Downloads section, www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

Another rule is that the single “initial” administration code should represent the main reason for the encounter, which in the example is the antineoplastic administration of cyclophosphamide. Consequently, the appropriate initial code for this example is 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

Because you can choose only one initial service code (96413) for this encounter, the appropriate code for the therapeutic hydration is “additional hour” hydration code +96361, not initial hydration code 96360.

CPT® guidelines further support reporting +96361 in the example case with these statements:

“If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported.”
“Report 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service [96360, 96365, 96374, 96409, 96413] is administered through the same IV access.”

So based on CPT®, MCPM, and CCI manual guidelines, you should report 96413 as the primary code for +96361 in the example case. Table I’s listing of 96360 as the only possible primary code for +96361 is incorrect and leaves coders no way to properly report secondary hydration services to payers applying the CCI rule.

Hold Out Until July 1 Correction

Fortunately, there’s light at the end of this tunnel. “CMS decided to revise the primary codes for code 96361, and will now include CPT® codes 96360, 96365, 96374, 96409, and 96413. The change will occur July 1, 2013, but will be retroactive to April 1, 2013,” announced the American Society of Clinical Oncology (ASCO) (http://ascoaction.asco.org/Home/tabid/41/articleType/ArticleView/articleId/477/CMS-Revises-NCCI-Edits-on-CPT-Code-96361.aspx).

For practices like Palmer’s, who are seeing this edit applied only by Medicare, the primary code change should resolve the problem going forward. But the retroactive nature of the change opens the question of how to handle claims for April, May, and June.

“We were advised to either hold all claims with the hydration codes, or appeal any denied claims after July 1,” says Palmer.

Nuske received similar advice from her payer — hold affected claims until July 1 or, the option Nuske prefers, appeal any denials that come in.

Buell and specialty societies, such as ASCO and Oncology Managers of Florida, are offering comparable recommendations.

Resource: You can review the Transmittal with add-on tables at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2636CP.pdf .