Oncology & Hematology Coding Alert

We bust drug claim errors that can steal your rightful dollars

You could be losing as much as 34 percent of your drug reimbursement if you fall prey to a few common coding pitfalls.

What to do: Try this handy breakdown of the top-10 underbilled oncology drugs to help you spot the culprits and know which HCPCS codes apply for these oncology underbilling offenders.

Know What to Watch for, Recoup 44 Percent More

During a recent Coding Institute audioconference titled "Solid Solutions for Serious Oncology Reimbursement Leaks," Cindy Acker, Tara Cameron, CPC, and Kelly Logan, ROCC, of the Claims Resolution Center (CRC) in Treasure Island, Fla., presented a list of the top-10 underbilled drugs.

Drug payments "have drastically decreased since 2004," and practices have been recovering only about 66 percent of the drug charges they could receive reimbursement for, Acker, Cameron and Logan say. Here are the drugs the CRC team singled out:

1. Analyze Lung Cancer Claims for Alimta

The most underbilled drug in the lineup, Alimta is a cancer medication that interferes with cancer cells by slowing their growth and spread throughout the body.

Practices lost out on as much as $75,000 in reimbursements for this drug due to underbilling in 2007, according to Acker, Cameron and Logan.

Almita's primary use is mesothelioma treatment (163.0-163.9, Malignant neoplasm of pleura) as well as non-small cell lung cancer (162.0-162.9, Malignant neoplasm of trachea, bronchus and lung) that has already been treated with other cancer medications.

How to code for it: Your HCPCS coding choice for Alimta is J9305 (Injection, pemetrexed, 10 mg).

2. Don't Let Avastin Get Lost in the Mix

Coming in at number two is Avastin, a cancer medication that impedes cancer cell growth and slows their spread throughout the body.

Your oncologist is likely to use this drug in colon and rectum cancer treatment (153.0-154.1, Malignant neoplasm of colon and Malignant neoplasm of rectum, rectosigmoid junction and anus) and will often combine the drug with other cancer medicines.

How to code for it: J9035 (Injection, bevacizumab, 10 mg) is your only option for Avastin.

3. Remember Kytril for Chemo

Oncology's number-three most underbilled drug treats and prevents the nausea and vomiting (787.0x, Nausea and vomiting) associated with cancer chemotherapy and radiation therapy. The drug blocks the actions of certain chemicals in the body.

How to code for it: For Kytril, use J1626 (Injection, granisetron HCl, 100 mcg).

4. Multiple Myeloma Means Zometa

Zometa treats high calcium levels in the blood associated with malignancy by inhibiting calcium release from bones, and your oncologist may use it to treat multiple myeloma (203.0x, Multiple myeloma) and Paget's disease (731.0, Osteitis deformans and osteopathies associated with other disorders classified elsewhere; osteitis deformans without mention of bone tumor).

How to code for it: To code for Zometa, use J3487 (Injection, zoledronic acid [Zometa], 1 mg).

5. Taxotere Serves Many Masters

A cancer medicine used to slow the growth and spread of cancer cells, Taxotere treats cancer affecting the breasts (174.0-174.9, Malignant neoplasm of female breast), lungs (162.0-162.9), prostate (185, Malignant neoplasm of prostate), stomach (151.0-151.9, Malignant neoplasm of stomach), and head or neck (for example 140-149, Malignant neoplasm of lip, oral cavity and pharynx).

How to code for it: For Taxotere, code using J9170 (Docetaxel, 20 mg).

6. Look to Dexamethasone When Side Effects Appear

Dexamethasone is a steroid oncologists use to prevent inflammation-causing substances from being released. It also helps counteract certain antitumor treatment side effects in chemotherapy patients, such as nausea (787.0x).

How to code for it: The appropriate HCPCS code for Dexamethasone is J1100 (Injection, dexamethasone sodium phosphate, 1 mg).

7. Remember Neulasta for Chemo Recovery Cases

A protein used to stimulate white blood cell production, Neulasta helps decrease infection risk in patients receiving chemotherapy for non-myeloid cancers.

How to code for it: Code for Neulasta using J2505 (Injection, pegfilgrastim, 6 mg).

8. Oxaliplatin Is Key When Coding 153.x Treatment

Oncologists typically use Oxaliplatin in combination with other medications to treat advanced colon or rectum cancer (153.0-154.1).

Oxaliplatin is an antineoplastic that kills cancer cells and slows tumor growth.

How to code for it: Your correct HCPCS choice is J9263 (Injection, oxaliplatin, 0.5 mg).

9. Code Carboplatin as Ovarian Cancer Combatant

Near the bottom of the list is another antineoplastic. Carboplatin disrupts cancer cell growth in ovarian cancer treatment (183.0-183.9, Malignant neoplasm of ovary and other uterine adnexa and 220, Benign neoplasm of ovary).

How to code for it: Coding for Carboplatin is easy using J9045 (Carboplatin, 50mg).

10. Don't Forget Faslodex for Breast Cancer Dx

Finishing out the top 10 is Faslodex, an estrogen receptor antagonist.

Oncologists use this drug in postmenopausal women who haven't responded well to therapy or other medicines -- such as antiestrogen drugs -- to treat certain advanced breast cancer types (174.0-174.9, Malignant neoplasm of female breast).

How to code for it: Use J9395 (Injection, fulvestrant, 25 mg) for Faslodex.

Put These Lessons Into Practice

Now it's time to apply what you-ve just learned. Here's an example: Your oncologist treats a patient undergoing chemotherapy for breast cancer (upper-outer quadrant).

The physician delivers 40 mg of Taxotere by infusion for one hour during the patient's chemo. You should report 96413 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug) for the Taxotere infusion, says Tammy Harrison, coder with Physicians East in Greenville, N.C.

Attach diagnosis code 174.4 (Malignant neoplasm of female breast; upper-outer quadrant). As with all breast cancer diagnosis codes, you will also need to include additional codes V86.0 (Estrogen receptor positive status [ER+]) or V86.1 (- negative status [ER-]) to identify the estrogen status of the patient's cancer. For the drug supply, report J9170 (Docetaxel, 20 mg) x 2.

Remember: Only the entity that bears the cost of the drug should bill for it.

Resource: For your own copy of "Solid Solutions for Serious Oncology Reimbursement Leaks," please visit http://www.audioeducator.com/industry_conference.php?id=703.