Oncology & Hematology Coding Alert

Missing out on separately reportable drug reimbursement could have you seeing red

Blood transfusions are par for the course when treating cancer patients, but knowing which codes to report and who may report them can be tricky. Don't let your payer stick it to you - we've got the lowdown on how to go with the flow on your next transfusion claim, including when to ask your patient to sign an Advance Beneficiary Notice (ABN).

Be on the watch: Oncologists are most likely to order a blood transfusion for a patient experiencing anemia due to chemotherapy, says Garnet Dunston, CPC, MPC, past secretary-treasurer of the American Academy of Professional Coders. Leukemia patients may need transfusions before and after chemo, and if your oncologist is also a hematologist, you may see reports for hemophilia or other coagulation defects, she adds.

Investigate 'Incident-To' Rules

In the office setting, nonphysician employees, such as registered nurses, oncology certified nurses, or other nursing staff, perform most blood transfusions.

Red flag: This means the employee needs to perform the blood transfusion under "incident-to" rules - before you code, be sure you have documentation that a practice physician was in the office suite and immediately available during the procedure.

Perform Separate Counts for Service and Supply

For a blood product, each pint equals one unit. Careful: Regardless of how many blood product units you use and report, only report 36430 (Transfusion, blood or blood components) one time.

Example: Your patient requires three units of packed red blood cells and three units of fresh frozen plasma. Your freestanding center supplies both the service and the blood products. Report one unit of 36430, three units of P9021 (Red blood cells, each unit), and three units of P9017 (Fresh frozen plasma [single donor], frozen within 8 hours of collection, each unit).

Remember: Carriers often won't pay unless you code for both the transfusion and the blood product. If you're a freestanding center that performs a transfusion, but the hospital supplies the blood, be sure to get an ABN in which the patient agrees to cover any charges Medicare won't. The ABN states that you suspect Medicare won't pay for the service and the patient must choose whether he is willing to receive the service knowing he may have to pay.

You should also include an estimate of the cost, have the patient sign and date the document, and give the patient a copy for his records. Watch for: Some private insurers accept "waivers of liability" similar to the ABN, so find out if your patient's insurance offers this reimbursement safeguard.

Inject Extra Reimbursement Into Your Claim

When you send in a claim for blood transfusion code 36430, your payer will typically include reimbursement for preparation and supplies (except blood products) with the 36430 payment. Good coding practice dictates that
you code for any supplies used - just don't expect separate reimbursement.

Good news: Many Medicare carriers and private payers will cover drugs administered just before, during, or immediately after the transfusion if you can show medical necessity.

Example: You can report drugs given to prevent reaction, such as Benadryl or Solu-Medrol, says Laura Hovey, CPC, reimbursement manager at Cancer and Hematology Centers of Western Michigan in Grand Rapids. Report Benadryl with J1200 (Injection, diphenhydramine HCL, up to 50 mg) and Solu-Medrol with J2920 (Injection, methylprednisolone sodium succinate, up to 40 mg) or J2930 (...up to 125 mg).

Don't Overlook Infusions

Although payers include infusions required for the transfusion in the transfusion code, if you can show separate drug administration through infusion, you should be reimbursed.

How to do it: Append modifier 59 (Distinct procedural service) to the infusion code, Hovey says. Report a nonchemo infusion with a code such as G0347 (Intravenous infusion, for therapeutic/diagnostic [specify substance or drug]; initial, up to one hour) or a chemo infusion with a code such as G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug). 

Or, if your payer asks for CPT codes instead, you may need to report 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) or 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour). 

You should also check the documentation for a diagnosis separate from the one behind the physician's order for the transfusion. A distinct diagnosis helps show medical necessity for the infusion, Hovey says.

Bolster Your Blood Product Coding

If you don't supply the blood: Only the provider who actually supplies the blood gets to report the code for the blood product. So if you're coding for a freestanding center, but a hospital supplies the blood, you may report the transfusion with 36430, but you shouldn't report the blood. Remember: This means you may not get paid, so obtain an ABN or work out a payment agreement with the patient prior to the transfusion.

If you do supply the blood: Look to HCPCS codes P9010-P9060 to report the blood product. You may need to include an invoice with your claim for reimbursement when you can legitimately report the blood.

Track Medicare blood deductible: Medicare won't pay for the first three units of whole blood or packed red blood cells a patient receives in a calendar year - a policy referred to as the Medicare Blood Deductible - so you may need an ABN to have the patient cover this cost.

The deductible applies to the first three units, regardless of whether more than one provider supplied them. The deductible doesn't apply to storing, processing, and administering the transfusion, or blood components other than packed red blood cells (platelets, plasma, etc.).
 
Translation: If you don't pay for the blood (because you got it for free or the patient or others donate enough blood in the patient's name), you shouldn't charge the patient. For more on the Blood Deductible, see section 3235 at www.cms.hhs.gov/manuals/13_int/a3201.asp#_1_9.