Oncology & Hematology Coding Alert

There are circumstances that require a patient to be placed in an outpatient hospital facility when chemotherapy is performed. This does not necessarily preclude the office-based oncologist from billing for related services. However, chemotherapy administration, 96400-96549, and office-based codes such as 99211-99215 (office or other outpatient visits) and 90780 (IV infusion for therapy/diagnosis) should not be used.

For coders looking for direction, there is a scarcity of information from the AMA on the correct application of chemotherapy codes in the hospital environment, but there is a wealth of information that Medicare carriers have published, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga.

Overwhelmingly, Medicare and private payers reject the notion of reimbursement for hospital-based chemotherapy administration. According to local medical review policies (LMRPs), payment for these services is nonreimbursable for physicians because it is not actually provided by the doctor or his or her staff.

Rather than the service representing an expense to the physician; it is a cost to the hospital, which supplies the room, equipment and nursing staff. Essentially, all the doctor is doing is writing an order, Parman says. There is, however, at least one billing opportunity, she explains.

My recommendation to a physician who admits a patient to the hospital for chemotherapy would be to bill only the E/M visit code for the evaluation. For example, when a patient is sent to an outpatient hospital facility for chemotherapy, and the physician performs an examination prior to the administration of the drug, the doctor should bill for the appropriate E/M of the patient, 99212-99215. The proper level of service is determined by the presence of the three key components of an office visit exam, history and medical decision-making.

The subsequent services administration of chemotherapy and anti-emetics are the domain of the hospital.

Exception to the Rule

According to Parman, hospital-based chemotherapy administration charges should be considered a Part A service, which is set aside for hospital and other facility reimbursement. The physician may provide a supervisory service to the pharmacy and nursing staff, but this is considered a benefit to the hospital and not separately reimbursed to the doctor by Part B, which is set aside for physician reimbursement.

As a result, the hospital would use inpatient chemotherapy codes Q0083, Q0084 and Q0085. Commercial payers, on the other hand, require hospitals to use codes such as 96410, 96412 and 90780 to describe the services provided by the facility staff, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinical director for the Tulane Cancer Center in New Orleans. The only exception that allows physicians to bill for the administration is if he or she actually performs it, whereby he or she would use the administration codes (96400-96549), Parman says. Still, this is a carrier-specific interpretation and coders should check with their local carrier before billing.