Oncology & Hematology Coding Alert

Oncology practice billing staffs often wrongly assume that the pump and venous access port are one and the same. Although both are integral parts in the infusion technique and ports must be flushed with heparin routinely to prevent clotting to guarantee proper pump function, Medicare considers them separate. Maintenance of a venous port should not be confused with the flushing of the implantable infusion pump, but there are billing options.

Some oncology practices mistakenly are using 96530 (refilling and maintenance of implantable pump or reservoir) to bill for the flushing and accessing of ports used during and after chemotherapy. According to Medicare guidelines and oncology coding experts, 96530 would lead to overpayment for a service that routinely is performed by a nurse without physician supervision.

Most of the time you cant bill for the procedure, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., a Dallas, Ga.-based coding consulting firm.

Its never an acceptable charge if it is done in conjunction with chemotherapy, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology, an oncology practice in Hooksett, N.H.

Medicare policy on using 96530 is clear as well. According to Medicare, the accessing and flushing of the implanted infusion pump and its attached catheter either in a large vein, the epidural or subarachnoid space is included in an appropriate evaluation and management (E/M) service code as part of managing the patient. In addition, CPT code 96530 should not be reported either for the flushing of the lumen(s) of a long-term central venous access device, such as a Hickman catheter, or an implanted venous access device port like the Port-a-Cath.

Medicare maintains that 96530 should be used only for refilling of the implantable pump or reservoir with appropriate medication. The relative value unit assigned to 96530 is too high to be associated with the low complexity of accessing and flushing ports, says Parman. In addition, Medicare guidelines state that 96530 will not be allowed on the same day as 96414 (chemotherapy administration; infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump).

According to Towle and Parman, the inappropriateness of 96530 is black and white, but oncology practices must navigate a subtle gray area when they try to bill for port flushing with other codes. In many instances, individual Medicare carriers determine the proper code, if one is available. Oncology practices should check with their local carrier to get the proper code for port flushing and codes associated with it.

Although maintenance of a venous port should not be confused with the flushing of the implantable infusion pump, Towle says her carrier, National Heritage Insurance Co., allows practices to use CPT code 99211 (office or other outpatient visit) for accessing and flushing of a catheter, line or port, when the service is distinct and separate from chemotherapy administration and other E/M services.

Use of 99211 depends on whether the flushing of the port is a separate and distinct service. In other words, the maintenance of the port is not part of chemotherapy treatment or a higher-level E/M visit in which the physician is present and the criteria of an E/M visit are met. Instead, oncology practices should bill the higher-level visit, 99212-99215, and consider the port flush as part of the office visit.

As an example of the different ways carriers require oncology practices to bill for port flushes, the following information is taken from the local medical review policies (LMRPs) of two carriers:

Blue Cross Blue Shield of Montana

Using venous access devices for blood collection and/or Heparin flush for any reason is part of managing the patient with this type of long-term venous device. It is included in the appropriate E/M service code and not allowed when billed separately, Blue Cross Blue Shield states. Supplies such as needles, syringes and Betadine wipes also are bundled with E/M services and not allowed when billed separately. Associated codes that are allowed include:

96549 unlisted chemotherapy procedure;
G0001 routine venipuncture for collection of specimen(s);
36415 routine venipuncture of finger/heel/ear stick for collection for specimen(s);
96408 chemotherapy administration, intravenous; push technique;
96530 refilling and maintenance of implantable pump or reservoir;
90784 therapeutic or diagnostic injection; IV; and
J1642 injection, Heparin sodium, 10 unit

In addition, the carrier advises its providers to follow these coding guidelines:

1. Appropriate E/M service code should be billed according to CPT coding guidelines. E/M service codes should not be upcoded to specifically indicate that blood collection or flushing was performed in addition to other services.

2. The CPT description of code 96549 indicates this code is to be used for unlisted chemotherapy procedures. It is not appropriate to bill separately for accessing a venous port for any reason, including administration of drugs and IV fluids, blood collection or flushing and maintenance of the port. This is part of managing the patient with this type of long-term catheter and considered inclusive in the primary service provided (i.e., appropriate E/M code).

3. HCPCS/CPT codes G0001 and 36415 are not the appropriate codes to bill for routine blood collection via a venous access port. These codes describe routine venipuncture for collection of specimens. Technically, venipuncture is different from accessing a port. Also, CPT code 96530 is not the appropriate code for blood collection and/or Heparin flushes.

4. Any additional code such as, but not limited to, 96408 and 90784 used to bill performance of a Heparin flush separately from an E/M service code is not allowed. HCPCS code J1640 may be billed for the cost of Heparin if used when flushing.

Wisconsin Physicians Service Co.

Flushing of a vascular access port prior to administration of chemotherapy, or other medically necessary drug administration, is integral to the drug administration and is not billable separately, this carrier states. If a special visit is made to a physicians office just for the port flushing, code 99211 should be used. Code 96530, while a payable service, should not be used to report port flushing.