Oncology & Hematology Coding Alert

Blood transfusions were once the sole domain of hospital outpatient departments. But more oncology practices are realizing the convenience they provide to their patients by performing this procedure in their office. As this trend continues, it is important for billing staff to recognize certain billing limitations, says Margaret Hickey, RN, MSN, MS OCN, an independent healthcare consultant and former clinical director at Tulane Cancer Center in New Orleans.

According to Hickey, oncology practices that perform blood transfusions (36430) in their offices risk running into problems with coding guidelines when they do the following:

1. Bill an evaluation and management (E/M) code, such as 99211 (established patient, office or other outpatient visit) in addition to 36430.
A transfusion, which is listed in the surgery section of the CPT, cannot be accompanied by an E/M visit code, Hickey says, because surgery guidelines prohibit using physician service codes along with surgery codes. Exceptions can be made with proof that the E/M service was a distinct and separate service.

2. Bill for the first three units of blood.
The first three units of blood per year are not covered. After the first three units are given to the patient, payment may be made for subsequent blood products. The cost of the first three annual units of whole blood (P9010) and red blood cells (P9021) is subject to a blood deductible. According to Hickey, the cost of the first three units is either absorbed by the physician or billed to the patient. (Practices can require Medicare patients to sign a waiver indicating that the first three units of blood are their responsibility.) Each unit beyond three can be billed using the above P codes. So, if a patients first transfusion requires four units, the practice would indicate one unit on the bill. Any subsequent use of blood can be billed in its entirety.

3. Bill for saline used in transfusion procedure.
Like the use of saline in chemotherapy, when saline is used to hydrate the blood during a transfusion it is considered a bundled procedure. I would say that the same rules that apply to chemotherapy, apply here, Hickey says.

4. Failure to follow incident-to rules.
While a physician doesnt physically perform the transfusion, he or she is still entitled to bill for the service. Despite the fact that a non-physician practitioner performs the service, the procedure falls under incident-to guidelines. The practice must ensure the following requirements are met to bill the procedure correctly:

A physician who is a member of the oncology practice but not necessarily the patients own physician must be present in the office at the time the mid-level provider or nurse performs the transfusion.

The physician assistant, nurse practitioner or [...]