Oncology & Hematology Coding Alert

Don’t let your coding skills get left in the past.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below.

Answer 1: On Jan. 1, 2023, Medicare introduced modifier JZ (Zero drug amount discarded/not administered to any patient). Unlike modifier JW (Drug amount discarded/not administered to any patient), which you use when your provider administers part of a single-dose container and discards the rest, Medicare instructed you to use the JZ modifier when the entire container is used as the dose administered and there is no discarded amount subject to modifier JW rules.

Even though modifier JZ had an effective date of Jan. 1, 2023, Medicare opted to give providers until July 1 to start using it. On Oct. 1, 2023, Medicare then began claims processing edits, checking use of both JW and JZ.

Tip: You should add the JZ modifier to the HCPCS Level II code claim line and include the number of units administered in the units field according to the HCPCS Level II code definition.

Answer 2: On Jan. 1, 2023, CMS introduced the following prolonged services codes for use with inpatient, observation, nursing facility, home, or resident visits:

G0316 (Prolonged hospital inpatient or observation care evaluation and management service(s) beyond the total time for the primary service …; each additional 15 minutes … (do not report G0316 for any time unit less than 15 minutes))

• G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service …; each additional 15 minutes … (do not report G0317 for any time unit less than 15 minutes))
• G0318 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service …; each additional 15 minutes … (do not report G0318 for any time unit less than 15 minutes))

As the descriptors state, you use G0316 to capture prolonged hospital inpatient or observation evaluation and management (E/M) service time along with primary service codes 99223 (Initial hospital inpatient or observation care, per day. … 75 minutes must be met or exceeded.), 99233 (Subsequent hospital inpatient or observation care, per day. … 50 minutes must be met or exceeded.), and/or 99236 (Hospital inpatient or observation care … including admission and discharge on the same date … 85 minutes must be met or exceeded.).

Similarly, you use G0317 when billing 99306 (Initial nursing facility care, per day, for the evaluation and management of a patient. … 45 minutes must be met or exceeded.) and/or 99310 (Subsequent nursing facility care, per day, for the evaluation and management of a patient … 45 minutes must be met or exceeded.), and G0318 along with 99345 (Home or residence visit for the evaluation and management of a new patient … 75 minutes must be met or exceeded.) and/or 99350 (Home or residence visit for the evaluation and management of an established patient … 60 minutes must be met or exceeded.).

Remember: Because you count total physician time on the date of the visit only, use G0316 when the primary services described by 99223 and/or 99233 meets or exceeds its total time by a minimum of 15 minutes. So, you’ll use G0316 in addition to 99223 when the total time for 99223 exceeds 75 minutes plus 15 minutes, or 90 minutes, for the primary service plus the prolonged service.

However, because CMS counts pre- and/or post-visit times on other dates for 99236, 99306, 99310, 99345, and 99350, “the time threshold to report the appropriate prolonged service code is higher than the minutes calculated when adding 15 minutes to the time associated with the primary code,” notes Leah Fuller, CPC, COC, senior consultant at Pinnacle Enterprise Risk Consulting Services, Kannapolis, North Carolina. “For example, while 99345 has a time of 75 minutes, 140 minutes must be met before G0318 can be reported. Be sure to review the table provided by CMS at www.cms.gov/files/document/r11842cp. pdf to accurately report G0316, G0317, and G0318,” Fuller adds.

Don’t forget: Also check payer preference on these codes. Some payers may prefer you to use +99418 (Prolonged inpatient or observation evaluation and management service(s). … each 15 minutes of total time) with 99223, 99233, 99236, 99255, 99306, and/or 99310 and +99417 (Prolonged outpatient evaluation and management service(s). … each 15 minutes of total time) with 99345 and/or 99350.

Answer 3: For 2024, ICD-10-CM introduced new codes to correspond with the Breast Imaging Reporting and Data System (BI-RADS), which “is commonly referenced in mammogram reports and classifies the breast density level into four categories from A to D,” according to Taylor Berrena, COC, CPC, CPB, CRC, CPMA, CEMC, CFPC, CHONC, coder II at MD Anderson Cancer Center at Cooper in Yorktown, Virginia.

The codes correspond to the following BI-RADS categories:

• R92.31- (Mammographic fatty tissue density of breast) corresponds to BI-RADS category A or 1, which describes breasts that consist almost entirely of fatty tissue with almost no dense tissue.
• R92.32- (Mammographic fibroglandular density of breast) corresponds to BI-RADS category B or 2, which describes breasts that consist of a few, scattered areas of fibroglandular density. Most of the breast tissue is still nondense or fatty.
• R92.33- (Mammographic heterogeneous density of breast) corresponds to BI-RADS category C or 3, which describes breasts that consist of a near equal ratio of dense to nondense tissue. Small masses may be hidden.
• R92.34- (Mammographic extreme density of breast) corresponds to BI-RADS category D or 4, which describes breasts that consist almost entirely of dense tissue, and the density is so extreme it can lower the sensitivity of the mammogram.

Each of the above codes require 6th characters to specify laterality: 1 for the right breast, 2 for the left breast, or 3 for a bilateral diagnosis. The new code group also includes R92.30 (Dense breasts, unspecified), which you’ll assign if the provider’s documentation doesn’t indicate a specific type of breast tissue density. You will rarely use this code, however, since you should now be able to match the documented breast tissue density into the four new code subcategories.