Oncology & Hematology Coding Alert
Differentiate Chemotherapy from Non-Chemotherapy Drugs for Proper Payment
The combination of 5-FU (J9190) and leucovorin (J0640) has become a common therapy for patients with colon cancer. As the regimen becomes more popular, there is potential for some practices to mistakenly report the delivery of both drugs with chemotherapy administration codes when only one is actually a chemotherapy drug. The Function of Each Drug Explains Coding If coders understand the role each drug plays in the treatment of colon cancer, it will become clear why 5-FU and leucovorin should not be reported using chemotherapy administration codes. 5-FU is the chemotherapy drug used to combat the cancer. Like many chemotherapy drugs, it can be highly toxic. One of 5-FU's side effects is that it reduces levels of folic acid. Folic acid helps red and white blood cell formation and the synthesis of hemoglobin. Leucovorin is indicated as an antidote to the toxic effects of folic-acid antagonists such as 5-FU.
Sometimes leucovorin is given in strong dosages, which require IV infusions over a longer period of time. In this instance, the administration should be reported using 90780 for the first hour and +90781 ( each additional hour, up to eight hours [list separately in addition to code for primary procedure]) for each additional hour. Methotrexate is another chemotherapy drug used with leucovorin to treat colon cancer. In this case, you should report 96410 for the infusion and J9260 for the drug. Know How the Drug Is Administered Adults are normally treated with 10 mg/m2 of leucovorin every six hours via intravenous or intramuscular injection. However, it also comes in tablet form. The same dosage applies, which could cause confusion regarding how the drug was administered. Coders must be certain of the route it was given to avoid getting paid in error for the wrong form. Prove Medical Necessity Leucovorin is used in a limited number of situations, colon cancer among them. According to Medicare guidelines, leucovorin is medically necessary under the following conditions: Note: Leucovorin is indicated for use in combination with fluorouracil to prolong survival in the palliative treatment of patients with advanced colorectal cancer. The use of leucovorin should be supported by listing any of the following diagnoses codes: For megaloblastic anemias: For pyrimethamine and trimethoprim toxicity: Medicare guidelines indicate that the patient's clinical record should document not only the diagnosis but the route and frequency that leucovorin is administered with the dosing schedules. In some cases, payers may require that the documentation be submitted with the claim to justify medical necessity.
"Leucovorin is often mistaken as a chemotherapy drug," says Stephanie Thompson, CPC, practice manager for Lexington Oncology Associates, an oncology practice in Kentucky. It is a support-care drug often referred to as a "rescue" drug that is used to combat the side effects of chemotherapy, adds Nancy Giacomozzi, office manager for P.K. Administrative Services, a physician practice billing firm in Lakewood, Colo. Instead of coding the administration of leucovorin using 96410 (... infusion technique, up to one hour), you should report 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) or 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician, up to one hour), depending on the mode of administration.
Under normal circumstances, 5-FU is pushed, followed by an IV injection of leucovorin. The claim form should list the following administration and drug codes:
You may not bill for administration of a tablet because Medicare and most other payers consider oral drugs to be self-administered. The cost of the drug is also not billable. In most cases the physician will write a prescription the cost of which is paid by the patient or the patient's insurance carrier.
Oncology & Hematology Coding Alert
- Colon Cancer:
Differentiate Chemotherapy from Non-Chemotherapy Drugs for Proper Payment
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