Oncology & Hematology Coding Alert

Report 78804 for diagnostic localization procedures

CPT 2004 offers radiation oncology coders two new codes - 78804 and 79403 - for the oncologist's nuclear medicine imaging and infusion therapy services. In addition, oncology coders can now bill implantable pump refills, thanks to new code 95991.
 
Specifically, when your radiation oncologist performs diagnostic tumor localization services or administers a preprocedure study that requires an analysis of radiopharmaceutical distribution, you may assign 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; whole body, requiring two or more days imaging) or 79403 (Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion).
 
For example, a physician may use radiopharmaceutical localization when testing chemotherapy drugs Zevalin and Bexxar. By using the localization technique, the physician can determine whether the radiopharmaceutical will target a patient's tumor or will concentrate in critical organs, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc., an Atlanta-based coding and consulting firm.
 
And, 78804 and 79403 replace HCPCS codes G0273 (Radiopharmaceutical biodistribution, single or multiple scans on one or more days, pre-treatment planning for radiopharmaceutical therapy of non-Hodgkin's lymphoma, includes administration of radiopharmaceutical [e.g., radiolabeled antibodies]) and G0274 (Radiopharmaceutical therapy, non-Hodgkin's lymphoma, includes administration of radiopharmaceutical [e.g., radiolabeled antibodies]). Therefore, after Jan. 1, you should report either 78804 or 79403 for Medicare patients.
 
CPT 2004 also revised related codes 78800 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; limited area) and 79400 (Radiopharmaceutical therapy, nonthyroid, nonhematologic by intravenous injection), Parman says. Because 78800 and 79400 now represent radiopharmaceutical agent distribution, you can use these codes for the physician's diagnostic tumor localization services, and for radiopharmaceutical localization, depending on the treatment area.

Choose 0061T Over Unlisted-Procedure Code

In 2004, oncology coders will have a new Category III code to report emerging technologies in malignant breast tumor treatments. Remember that insurers may or may not pay for 0061T (Destruction/reduction of malignant breast tumor including breast carcinoma cells in the margins, microwave phased array thermotherapy, disposable catheter with combined temperature monitoring probe and microwave sensor, externally applied microwave energy, including interstitial placement of sensor), because many payers consider Category III codes to represent experimental procedures, Parman says.
 
Report Category III codes rather than an unlisted-procedure code when the physician performs a procedure he describes, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CMSCS, a healthcare coding consultant based in Laguna Beach, Calif., and American Academy of Professional Coders National Advisory Board member.

Update Your Pump Refill Coding

You now have a new code for the oncologist's pump refill services. CPT 2004 adds 95991 (Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal [intrathecal, epidural] or brain [intraventricular]; administered by physician) so that physicians can report refilling and maintaining implantable pumps or reservoirs for drug delivery.
 
The typical patient for pump refills will probably have  severe cancer-related pain, such as advanced pancreatic cancer (157.x, Malignant neoplasm of pancreas). Gynecologic oncologists will probably use this code most, says Judy Troy, an ob-gyn coder with 35 years of experience and surgical coding coordinator for Capital Women's Care in Silver Spring, Md. You should use revised code 95990 (Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal [intrathecal, epidural] or brain [intraventricular]) only when a nonphysician provides the service.
 
Although not all oncologists perform catheter and line access services, your oncologist may perform peripherally inserted central venous catheter (PICC) maintenance. In that case, you could report new codes 36575 (Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site) or 36584 (Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access).

Use 36400 for Physician Venipuncture

If you assign 36400 to your oncologist's routine venipuncture services after Jan. 1, 2004, you can expect denials, because CPT 2004 revises 36400 to represent an unusual venipuncture procedure.
 
Now oncology coders may report 36400 (Venipuncture, under age 3 years; femoral or jugular) when the nurse draws blood from a child under 3 years of age who, for instance, has leukemia (208.xx, Leukemia of unspecified cell type).
 
But with CPT 2004, the AMA introduces this 36400 descriptor: Venipuncture, under age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein. The new definition means that only oncologists, not the nurse or phlebotomist, may bill for 36400. The code now requires that the physician perform an unusual venipuncture.
 
When you report 36400, you'll need to make sure the documentation clearly shows that the oncologist performed the procedure and that the patient's condition required the physician personally to perform the venipuncture, coding experts say.
 
If, for example, your nurse or phlebotomist couldn't obtain a child's blood specimen due to poor venous access, and your oncologist withdrew blood from the femoral or jugular vein, you could report 36400. But make sure the documentation shows that the nurse or phlebotomist couldn't obtain the specimen.
 
CPT 2004 also revamped the definition for adult venipuncture. But you should still report 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]) for unusual venipuncture services the oncologist performs on children older than 3 years and on adults.

Remember that the physician may charge for venipuncture as long as the fee doesn't exceed $3 per patient, according to the Medicare Carriers Manual. And  remember the following criteria when reporting venipuncture: