Oncology & Hematology Coding Alert

"Putting the right codes in the right order helps get claims paid promptly. Any claims that include epoetin-alpha, Q0136, (EPO [Epogen, Procrit]), a biological response modifier, require a different order than claims for chemotherapy claims. Epogen and Procrit (epoetin-alpha, Q0136) are adjuncts to chemotherapy, used to treat chemotherapy-related anemia. The most important thing is to match the right ICD-9 with the appropriate CPT-4 or HCPCS codes. Although Medicare guidelines require that claims be transmitted electronically, not all software vendors have the electronic notepad working properly to complete Block 19 of the HCFA 1500 form. This form requires additional information for certain procedures and injections administered in an outpatient setting. Because of this, hard copy claims with notes from the office visit attached can actually save time, especially on the initial claim.

Medicare guidelines require the billing of epoetin-alpha (Q0136) as follows:

Initial Claim

Procedure code: Chemotherapy infusion up to 1 hour (96410); 1-8 hours (96412). Units: 1 (always one).

Diagnosis code 1: (anemia code285.9).

Diagnosis code 2: (cancer code, such as 174.4 for breast cancer, upper outer quadrant).

Diagnosis code 3: (chemotherapy patient V58.1). Chemotherapy drug code (Epogen or Procrit [epoetin-alpha, Q0136]) and units. Block 19 of HCFA Form 1500 must also include: Patients weight in kilograms (for example 140 lbs*/*2.2 = 63.64 kg). Patients starting dosage per kilogram of body weight, date and results of the most recent hematocrit (HCT) and hemoglobin (Hgb) and EPO level prior to initiation of therapy, date and results of the most recent HCT/Hgb (within two months, if different from the above value). If the recommended starting dosage of 150 units/kg of three times per week is exceeded, include the reason for exceeding the recommended dosage. If starting EPO therapy when the HCT/Hgb levels are higher than 30%/10 and/or the EPO level, include the reason for starting therapy at this level. The total number of units administered in the billing period.

Subsequent Claims

On the second and subsequent administration of epoetin-alpha (Q0136), Medicare requires the addition of the EJ modifier indicating that this is a subsequent claim for which detailed documentation is not required. Remember that the HCFA Form 1500 allows six procedures to be billed per page. When billing infusion services 96410 and 96412, they must be listed with 96410 first and 96412 second, and on the same claim or the 96412 will be billed separately and not paid because it was billed alone.

Diagnostic coding should be in the same format as initial claim. Total units administered in the billing period. Date and results of the most recent HCT/Hgb levels obtained prior to the current therapy. Patients weight. If the recommended maximum dosage of 300 units/kg three times per week is exceeded, indicate the reasons why. If continuing epoetin-alpha (Q0136) beyond the target hematocrit/hemoglobin levels of 36%/12, medical justification must be submitted for consideration.

Tip: Carefully review the explanation of benefits on chemotherapy drugs to make sure carriers are paying the current average wholesale price (AWP) plus the percentage specified in your managed care contracts.

Drug prices change often and charges need to be increased to accommodate the cost. You can get quarterly updates on approved indications and prices for cancer chemotherapy drugs and their adjuncts online from the Association of Community Cancer Centers (ACCC) Compendia-Based Drug Bulletin. The ACCCs Web address is www.assoc-cancer-ctrs.org. For a free hard copy of the Bulletin, contact Donald Jewler, Publications Director, ACCC, 11600 Nebel St., Suite 201, Rockville MD 20852, 301/984-9496."