Oncology & Hematology Coding Alert

Reimbursement for chemotherapy administration is often barely enough to account for the supplies, nursing services and other related costs. Rather than writing off supplies as included in payment for chemotherapy services, oncology practices should consider whether they are missing allowable billing opportunities. Not all supplies are bundled with chemotherapy administration or an office visit.
 
"Supplies are usually not payable," says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H. "However, they are not completely off-limits."
 
As long as there is a possibility for rightful reimbursement, oncology practices should try to collect payment, says Stephanie Thompson, CPC, practice manager for Lexington Oncology Associates, an oncology practice in Lexington, Ky. She says, "If you are staying within guidelines, you should try for an appeal."
 
CMS says reimbursement for chemotherapy administration (96400-96549) includes payment for supplies for the procedure.
 
Private insurance payers, on the other hand, may leave this point open for negotiation. Unless the contract between the payer and oncology practice specifically states that supplies are included as part of payment for administration, practices may be able to bill for some items.

Supplies that are included in Medicare payment for chemotherapy administration include needles, tubing, IV setup, gauze, syringes, butterfly set, cotton, tubing, tape and catheters. However, items such as needles and syringes (A4206-A4209) and blood tubing arterial or venous (A4750) are often reimbursed by commercial payers.
 
When these items are used during non-chemotherapy-related procedures, such as a port flush or the administration of a non-chemotherapy drug (90780-90781), they should not be billed separately from the visit code (99211-99215).
 
Huber needles (A4212) are the only exception, Thompson says. This specialized, expensive needle is often used with an implanted or external port used during chemotherapy infusion.

Surgical trays (A4550) include many of the items included on the list that Medicare bundles with chemotherapy or other oncology-related procedures. In most cases, these trays are still not reimbursed by Medicare, but some carriers may reimburse for surgical trays.
 
"This is kind of a gray area," Thompson says. "Some practices are billing for trays because their carriers allow it. However, usually a surgery code should be associated with a surgery tray for separate reimbursement."    

A surgery-related procedure that can include separate payment for a surgical tray is a bone biopsy, 20220-20245. Sometimes referred to as bone biopsy trays, surgical trays can be appropriately reported when a practice performs bone biopsies. 
 
Private payers may reimburse for trays in addition to reimbursement for chemotherapy administration or an office visit. For example, many commercial payers will reimburse between $30 and $40 for surgical trays. This requires some up-front work by the practice. To plead their case, practices must be able to show that their costs exceed reimbursement without separate payment for supplies. It also requires thorough cost accounting by the practice, which should illustrate each cost item related to every covered procedure.

Oncology practices can bill Medicare and commercial carriers for saline or heparin (J1642) when it is used for hydration therapy. The key is knowing what Medicare considers hydration therapy. 
 
Hydration therapy involves prolonged intravenous infusion of saline or other fluids to maintain or reconstitute a person's intravascular fluid volume. Also, the following should not be considered hydration therapy and should not be used to report the use of saline:
 

The infusion of saline at the same time as a chemotherapy infusion, 96410-96412.
 

When the sole purpose of saline is to maintain patency of the access device. This is not hydration therapy because it is neither diagnostic nor therapeutic.
 

Administration of fluid in the course of transfusions to maintain line patency, or between units of blood product.
 

Administration of fluid to maintain line patency or flush lines between different agents given at the same chemotherapy session.
 

Saline used to dilute medication as directed in the instructions for chemotherapy drug preparation.

It is important to note the common theme among the scenarios that excluded separate payment of saline. Saline used to maintain lines and devices for chemotherapy administration and non-chemotherapy drugs is not covered, while saline used to address maintaining a well-hydrated vascular system is covered.
 
Medicare rules stipulate that the administration of fluids for maintaining vascular access between courses of chemotherapy at the same session is essential for chemotherapy and is not separately billable. This includes port flushes. However, if a practice can show that the port flush is a distinct and separate service from the chemotherapy administration such as when a special visit is made to a physician's office just for the port flushing 99211 (office or other outpatient visit) should be coded for the procedure, and saline can also be billed.