Oncology & Hematology Coding Alert

Learn which code you should add for patients on tamoxifen therapy.

Skipping secondary ICD-9 codes can be tempting, but properly reporting estrogen receptor status is a quick way to add support to your breast cancer patients' claims. Shore up your V86.x coding skills with the answers to three key questions.

Important: These questions and answers relate to patients being treated for breast cancer that is currently present, not for patients on prophylactic regimens.

1. What Do ER+ and ER- Refer To?

The following codes describe estrogen receptor status:

• V86.0 -- Estrogen receptor positive status [ER+]
• V86.1 -- Estrogen receptor negative status [ER-].

When a neoplasm is ER+, estrogen is fueling the cancer and causing it to grow. As a result, ER+ cancer should respond to hormone therapy. ER- cancers won't respond as well to hormone therapy. So ER status is important information for the oncologist when making treatment decisions.

Treatments: Hormone therapies that V86.0 may help support include the following:

• Selective estrogen receptor modulators (SERMs), such as oral drug tamoxifen (Nolvadex)
• Aromatase inhibitors (AIs), including oral drugs anastrazole (Arimidex) and letrozole (Femara)
• Estrogen-receptor down regulators (ERDs), such as fulvestrant (Faslodex) for post-menopausal women with advanced breast cancer that has stopped responding to other anti-estrogen therapy.

Caution: You should not report the orally administered drugs on your part B claim.

But providers administer fulvestrant (J9395, Injection, fulvestrant, 25 mg) as an intramuscular injection. So if you supply the drug, you may report it on your claim. Fulvestrant is given as a 250 mg dose, so be sure to report 10 units of J9395.Your administration code may vary depending on your payer. You may report chemotherapy admin code 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic) for fulvestrant administration, says Lorrie Andries, CPC, business office supervisor for Hematology Oncology Life Center in Alexandria, La.

Other payers may categorize fulvestrant as a non-antineoplastic hormonal treatment and require you to report 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). CPT guidelines indicate that you should report 96372 for non-antineoplastic hormonal therapy injections.

2. Who Identifies ER Status?

A lab test will reveal the patient's estrogen receptor status. Depending on whether the lab performs an analysis that is qualitative, semi-quantitative, or quantitative, and whether the technique is manual or automated, the lab should consider the following three codes:

• 88342 -- Immunohistochemistry (including tissue immunoperoxidase), each antibody
• 88360 -- Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/ progesterone receptor), quantitative or semiquantitative, each antibody; manual
• 88361 -- ... using computer-assisted technology.

The American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP) recommend designating a tumor as ER positive if at least one percent of the cells examined test positive. You may see results recorded as positive or negative, as a percentage (between 0 percent and 100 percent), or as a score:

• 0 for no receptors found
• 1+ for a small number of receptors found
• 2+ for a medium number
• 3+ for a large number.

Rule: Base your diagnosis on the physician's documented interpretation of the test.

Remember, ICD-9 guidelines state: "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses" (section IV.L, www.cdc.gov/nchs/data/icd9/icdguide09.pdf).

3. Should V86.x Be First-Listed?

When submitting V86.x on your claim for a patient who is currently being treated for breast cancer, be sure to follow ICD-9 guidelines about reporting order. A note with the V86.x codes states, "Code first malignant neoplasm of breast (174.0-174.9, 175.0-175.9)." The referenced codes are:

• 174.x -- Malignant neoplasm of female breast
• 175.x -- Malignant neoplasm of male breast.

ICD-9 rules state that the "code first" instruction "directs the coder to sequence the underlying condition before the manifestation." So, you should report the neoplasm before reporting the estrogen status.

Similarly, notes with 174.x and 175.x instruct you to "Use additional code to identify estrogen receptor status (V86.0, V86.1)." The "use additional code" instruction means "another code may be needed," ICD-9 states. So if a breast cancer patient has been tested for estrogen receptor status, you should report the appropriate V86.x code secondary to the malignant neoplasm code.

Example: To code a visit for a female patient with breast cancer (ER+ status) being treated with tamoxifen, you should report 174.x, says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey.

"If possible, be specific with the primary breast cancer code," she adds. "Review the chart for the location of the breast mass. It is possible to have two masses in different locations of the breast, and in that case, both breast cancer codes should be reported," Matola says. For example, you may report 174.2 (... upper-inner quadrant) and 174.4 (... upper-outer quadrant) together, she says. (For more information on 174.x, see "174.x in Focus" below.)

As a secondary diagnosis, list V86.0 (ER+ status). Plus, "if the chart note mentions family history of breast cancer, code V16.3 [Family history of malignant neoplasm; breast] may also be added as a secondary diagnosis," Matola notes.

In addition, V58.69 (Long-term [current] use of other medications) is appropriate when the patient is taking tamoxifen as part of current cancer treatment, according to ICD-9 Coding Clinic (October 2008). You should also check for other appropriate V codes, such as V58.83 (Encounter for therapeutic drug monitoring) when the patient presents to monitor the drug's effect.

Watch for: Oncologists may prescribe tamoxifen for prevention as well as for treatment of cancer, so pay close attention to the documentation. Look to a future issue for information on coding for patients taking tamoxifen as a preventative measure.