Oncology & Hematology Coding Alert

Remember to check your payer's self-administered drugs list to prevent denials.

Coding for prostate, bladder, and other urologic cancer therapy involves its own set of challenges, such as finding drug and administration codes for hormonal anti-neoplastics. Give your claims a leg up with a closer look at common therapy agent codes and administration coding strategies.

Hang on to This Handy HCPCS List

When coding for urologic oncology, you should familiarize yourself with the therapeutic agents your office uses most often. These may include the ones in the table below.

In addition to the drug HCPCS code, you should note the dosage or units administered. Also keep in mind that when you submit a claim for drug payments, in many cases the payer may require the full drug name, the total dosage or units administered, method of administration, and the National Drug Code (NDC) number.

Tip: Before submitting a claim to your Part B contractor, be sure to review its latest list of the drugs it won't cover because it considers them to be typically self-administered. For instance, you may find that your contractor won't cover luteinizing hormone-releasing hormone (LHRH) analogs coded with J9218 (Leuprolide acetate, per 1 mg) or J1675 (Injection, histrelin acetate, 10 micrograms) because patients usually can perform their own injections of these agents.

Remember That LCA Is Out for Reimbursement

In the past, some payers including Medicare would adjust your payment for drug codes down to the same level as the drug within the same classification with the lowest Average Sales Price (ASP). This was also known as applying the Least Costly Alternative (LCA).

The LCA policy said that if you have two products and both products produce similar acceptable results, but one product price is higher than the other, the reimbursement will be the cost of the lower priced product, explains Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla. and Brooklyn, N.Y. In other words, payment was based on the idea that if there was no substantive evidence that the higher priced product produced superior results, then there was no need to use it and the lower priced product should have been utilized. Therefore, reimbursement [would] only be as high as the 'least costly alternative.'

However, following a ruling by the US Court of Appeals, CMS released a directive effective April 19, 2010, that MACs were required to stop using LCA for all Part B drugs and were restricted from implementing LCA in any new LCDs. As a result, payers should now be reimbursing you using ASP-based payment rates (See also: Medicare Claims Processing Manual, Chapter 17, Section 20, www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c17.pdf).

Choose the Proper Administration Code

Once you've nailed down the proper drug supply code, you need to select the appropriate administration code. You should choose between:

• 96365-96379: therapeutic, prophylactic, and diagnostic injections and infusions
• 96401-96425: chemotherapy and other highly complex drugs or biologic agents.

Remember that one key factor in choosing the proper administration code is pinning down the route of administration. For instance, injections of testosterone, antibiotics, and other agents such as B12 or Epogen require an appropriate injection code, such as 96372 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), rather than an intravenous infusion code.

Example: The nurse administers 4 mg IV Zometa over a period of 15 minutes. According to the code descriptor for Zometa (J3487, Injection, zoledronic acid [Zometa], 1 mg), you will report the 4 milligram dosage with the number 4 in column 24G of the CMS-1500 form (or the electronic equivalent) to indicate 4 milligrams were given (1 unit per mg). Because the Zometa infusion was less than 16 minutes, you should use push administration code 96374 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; intravenous push, single or initial substance/drug).

Tip: Check with your major payers when new drugs are introduced into the market, says Karla Dickerson, billing and reimbursement coordinator at Salina Urology Associates in Kansas. Payers look at new meds differently and may have different opinions on what administration code is most fitting. [An] example would be CPT® code 96402 [Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic]. The code description indicates 'chemotherapy administration,' but the heading in the code section makes reference to not only chemotherapy medications but 'other highly complex drugs or biological agent administration.' Some payers may choose to include non-chemotherapy medications as the best fit to use with this administration code. Payers base the choice on the determination of the given agent's administration risk using clinical information from the FDA or other clinical recommendations or findings.

You'll have to watch for the opposite, as well. For instance, while many payers consider Trelstar admin to fit neatly under code 96402, other payers may instruct you to use the lower paying therapeutic injection code 96372 based on their determination of the admin risk. Because payers have different views of admin risk, you have to be alert for different reporting requirements.

Additionally, many drugs have specific frequency issues and can be administered and billed for only on a certain schedule, says Elizabeth Hollingshead, CPC, CUC, CMC, CMSCS, corporate billing/coding manager of Northwest Columbus Urology in Marysville, Ohio. You don't want to give Lupron several weeks early. That's a pretty large bill to eat, as are many others. Check with your carriers as this can vary state to state. Some allow an injection or infusion every X number of days while another might put it in weeks or months. Also, don't forget to check if a prior authorization is required, Hollingshead advises.