Oncology & Hematology Coding Alert

Hint: Remember to apply modifier JW.

New year, new problems? Hardly. Coding chemotherapy claims remains a complicated task for oncology coders. If you’re missing any details about the administration, medications, and underlying conditions, you could be setting yourself up for another year of headaches.

Start 2019 on the right foot by taking this chemotherapy challenge. Read the detailed example, then test your understanding by answering three key coding questions.

First, Read Over This Scenario

A patient diagnosed with a malignant neoplasm of the large intestine receives the following chemotherapy regimen. Table 1 lists the medications the patient received and the dose and route of administration.

Here’s How to Reflect Continuous Pump and Piggy Back Infusions

Question 1: What procedure codes will you report for the administration of medications listed in table 1?

A) 96413, +96415, 96416, +96367
B) 96413, +96415, +96411 x 2, +96367 x 2
C) 96413, +96415, +96411 x 2, +96367 x 2, +96368
D) 96413, +96415, 96416, +96367 x 2

Answer 1: The correct answer is option D.

According to CPT^® guidelines for infusions, you need to choose your initial administration service code based on the primary reason for the infusion—even when you’ve got multiple infusions, injections, and combinations. The order in which the physician administered them doesn’t matter.

Exception: Things are a little different when protocol requires the doctor to use two separate IV lines.

In this example, chemotherapy was the primary reason for the visit services, as the patient received oxaliplatin, a chemotherapeutic medication, for 1 hour and 50 minutes. So that’s why you should report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and +96415 (… each additional hour (List separately in addition to code for primary procedure)).

After the chemo infusion above, the oncologist initiated an IV infusion of fluorouracil using a portable pump. For this service, submit code 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump).

Prior to both services, the oncologist administered dexamethasone and palonosetron (Aloxi), piggy backed for 20 minutes each subsequent to each other. That’s two infusions, of two drugs, at two separate times. You should report +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]) for each of these infusions. Therefore, reporting two units of +96367 is appropriate.

Heads up: Be cautious. If the Dexadron® and Aloxi® medications were mixed together in the same bag/given over the same time, you would only report one unit of 96367 for the length of time infused.

Not so fast: You should not report the administration of the D5W solution.  The oncologist used the fluid to keep the line open (for line patency) and is considered incidental hydration.

Bill Correct Units for Drug Administered

Question 2: What are the HCPCS Level II codes for the administered medications listed in table 1?

A) J9190 x 10, J9263 x 292, J1100 x10, J2469 x10, J0641 x 690, J7042
B) J9190 x 10, J9263 x 292, J1100 x10, J2469 x10, J0641 x 345, J7042
C) J9190 x 10, J9263 x 292, J1100 x10, J2469 x10, J0641 x 345
D) J9190 x 9, J1100 x10, J2469 x10, J9263 x 292 and J9263-JW x 8 if waste occurred and is documented.

Answer 2: The correct answer is option D. Here’s a break down of these codes.

Fluorouracil, an antineoplastic drug, is a fluorinated analogue of uracil. You should submit HCPCS code J9190 (Injection, fluorouracil, 500 mg). In the example, the patient received a total of 4128 mg of fluorouracil. Since the HCPCS code unit is in 500mg increments, you round to the next highest unit to represent the amount given as 9 units of J9190. (See Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals, Section 10 Payment Rules).

Decadron (Dexamethasone) is a synthetic corticosteroid similar to the endogenous hormone produced in the adrenal gland. For every 1 mg of dexamethasone, you should submit one unit of code J1100 (Injection, dexamethasone sodium phosphate, 1 mg). In the example, the patient receives 10 mg of dexamethasone, so you submit 10 units of code J1100.

Aloxi (Palonosetron) is a chemical compound that is a selective blocker of serotonin 5-HT3 receptors. Oncologists use it for the prevention and treatment of nausea and vomiting associated with chemotherapy. For every 25 mcg of palonosetron, you should submit one unit of code J2469 (Injection, palonosetron HCl, 25 mcg). In the example, the patient receives 0.25 mg of palonosetron, which results to 10 units of J2469 when converted to mcg.

Oxaliplatin is a chemical complex containing the metal, platinum and used as an antineoplastic drug. You should submit code J9263 (Injection, oxaliplatin, 0.5 mg). So, for the oxaliplatin dose administered of 146 mg, you should report 292 units of J9263.

Important concept: “We are not finished with oxaliplatin just yet,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina. You’ll see oxaliplatin supplied in 50 mg or 100 mg single dose vials (“SDV”). Let’s assume one (1) vial of 100 mg and one (1) vial of 50 mg were used to prepare the infusion. The amount from both vials represents 150 mg. “Since the entire amount wasn’t captured with the HCPCS code reported for the dose given, the remaining amount from the last vial can be reported as waste,” Loya says. The wastage amount of 4mg from the second vial would be reported on an additional line on the claim with the modifier JW (Drug amount discarded/not administered to any patient) appearing as 8 units of J9263 (1 unit for each 0.5 mg of oxaliplatin wasted). “The amount of the drug wasted must be clearly documented in the patient’s medical record in order to be billed and reimbursed in both the office and hospital outpatient facility settings,” Loya says.

Be Specific for Diagnosis Codes

Question 3: Which of the following ICD-10-CM codes do you submit for this patient who has been diagnosed with malignant neoplasm of the large intestine and reports for chemotherapy administration?

A)  C18.9
B) Z51.11
C) Z51.11, C18.9
D) C19

Answer 3: The correct answer is option C.

Since the patient reports for administration of chemotherapy, you submit ICD-10-CM code Z51.11 (Encounter for antineoplastic chemotherapy) as the primary diagnosis code.

Since site of the neoplasm in the colon is not specified, you submit ICD-10-CM code C18.9 (Malignant neoplasm of colon, unspecified). You do not submit ICD-10-CM code C19 (Malignant neoplasm of rectosigmoid junction) as this code is specific for the neoplasm in the rectosigmoid junction.