Oncology & Hematology Coding Alert

Check with payer for reimbursement and do not miss the pre-medications.

Blinatunomab (Blincyto TM) is indicated for the treatment of Philadelphia chromosome-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia (ALL).  Submitting a claim for blinatumomab can leave you confused. Without a definitive code for blinatumomab, you will have to ensure you submit the best applicable code to strengthen your claim. Here are three simple steps to earning your payment for blinatumomab.

1. Different Administration Situations will Require Different Coding for Blinatumomab

Various Insurance Carriers may differ on their approach for reporting blinatumomab. This drug is classified as a monoclonal antibody with potential immunostimulating and antineoplastic activities.  When the treating provider orders the therapy for home use by the patient via an external infusion pump, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated blinatumomab (Blincyto™) and determined it is eligible for inclusion in the DME External Infusion Pump Local Coverage Determination (LCD). 

For dates of service on or after December 3, 2014, submit HCPCS code J7799 (NOC drugs, other than inhalation drugs, administered through DME) on claims for Blincyto™.  Make sure you enter the necessary information in the appropriate sections of your claim. For an electronic claim, focus on the narrative fields (NTE 2300 or NTE 2400) and for paper claims, look at Item 19. Be sure the details for name of the drug, dosage, total amount dispensed, and administration instructions are appropriately entered. 

“However, when the infusion is provided ‘incident to’ a physician’s services and initiated in the physician office, the medication is to be reported with an unclassified HCPCS code,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. “At this time, carriers are requiring different coding of this medication. For example, Molina published their list of Medications requiring prior authorization and list three (3) different HCPCS code to use for this medication. http://www.molinahealthcare.com/providers/common/PDF/Illinois/physician-administered-medications-requiring-medical-authorization-codes.pdf.”

However, Medicare Administrative Contractors have indicated J9999 is the unclassified medication HCPCS code to be used.  Yet there is one other option, HCPCS code C9399 would be reported on the UB-04 when provided to patients in an outpatient hospital setting. Each code definition is listed below:

• J3490 -- Unclassified drugs
• J3590 -- Unclassified biologics 
• J9999 -- Not otherwise classified, antineoplastic drugs
• C9399 -- Unclassified drugs or biologicals

Does your payer cover blinatumomab? Another challenge you may encounter is while the FDA approved the medication late last year, your payer may not yet cover or has not yet addressed coverage of blinatumomab. Check payer policies and prepare your supporting documentation accordingly. 

2. Code the Chemo Administration

To code the administration of blinatumomab, you should remember this new drug is given by intravenous infusion.

Therefore, when your oncologist provides the infusion for up to one hour, you assign 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). Medicare reimburses chemotherapy administration code 96413 at $135.87.

If the infusion lasts more than one hour, but less than eight, report +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]) for each additional infusion hour.

“If the infusion is initiated in the physician’s office using a portable/programmable infusion pump, and the infusion is set to last longer than 8 hours, report 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump),” Loya says.

Check the facility for drug administration: When your patient is a Medicare beneficiary who gets the drug every 48 hours in an unsupervised home setting, the claims for blinatumomab will be submitted by a DME supplier to the DME MACs. Unlike administration at a hospital/outpatient infusion facility, administration in a home setting with drug cassette exchanges may not require supervision. 

3. Check for Any Premedication

Your physician may premedicate the patient with dexamethasone. For example, your physician may administer 20 mg dexamethasone intravenously over 16 minutes, 1 hour prior to the first dose of blinatumomab of each cycle. In this case, you report the HCPCS code J1100 (Injection, dexamethasone sodium phosphate, 1mg). You report one unit of this code for every 1 mg of dexamethasone sodium phosphate your physician administers. 

Calculate units of J1100: If 10 mg of dexamethasone was administered, report 10 units of J1100.

Do not miss the administration code: Do not consider the administration of dexamethasone infusion as chemotherapy administration. For these infusions, you’ll use the appropriate “Therapeutic, prophylactic, or diagnostic injection” code (96372-96376). “If the dexamethasone was the only medication administered prior to initiating the prolonged infusion, you report the initial administration code based on the route of administration,” Loya says.  If there was another medication given, it may be reported with the secondary (or additional infusion/injection) codes. Although the therapeutic, prophylactic and diagnostic administration codes are in a different section than the chemotherapy infusion codes, you should not report a non-chemotherapy initial code if a chemotherapy administration is the initial service. 

To report the 16-minute dexamethasone infusion, you should use +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: The administration of dexamethasone is a 16-minute service, i.e. it is an infusion and not a push. Per CPT®, the definition of a push is “(a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, OR (b) an infusion of 15 minutes or less.” Because this service took and was recorded as 16 minutes of time to administer, you should report it as an infusion.

Earn for each infusion: You may read that your physician administered multiple infusions of the dexamethasone during the treatment cycle. For example, your physician may administer dexamethasone prior to a step dose, such as Cycle 1 day 8, or when restarting an infusion after an interruption of 4 or more hours. In this case, you should report the most appropriate administration code one for each infusion on the date of service. Also, code each dose of dexamethasone with appropriate units of J1100.