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 nurse is employed by the oncology practice.

The procedure represents an expense to the practice.

Incident-to services can occur without professional services occurring simultaneously, but they must be a part of the services that are part of the course of treatment, and reflect the physicians active participation in the management and care of the patient.

The physician should perform direct, personal and professional service to initiate the course of treatment of which the non-physician practitioner is an incidental part. There should also be subsequent services performed by the physician showing active participation in the care and treatment of the patient.

Direct supervision does not mean the physician must be in the same room with the nurse or other clinical staff member who is providing incident-to services, but that the physician must be in the office while incident-to services are being given. According to Medicare guidelines, a physician must be present in the office and immediately available to provide assistance and direction to the staff member performing the incident-to service.

Medical Necessity

The key to getting paid is proving medical necessity. Oncology practices should show that the transfusion was used to restore blood volume after hemorrhage, to improve the oxygen-carrying capacity of blood in severe anemia, or to combat shock in acute hemolytic anemia to demonstrate medical necessity.

Some diagnoses codes that Medicare recognizes as documentation proving medical necessity are leukemia (204-208.9), aplastic anemia (284.0-284.9), lymphomas (202.0-202.9) and breast cancer (174.0-174.9).

Situations in which transfusions are needed include:

Platelet replacement when platelet counts are low, the patient may receive platelet transfusions (36430) as protection against bleeding.

Red blood cell replacement to combat fatigue caused by chemotherapy-induced anemia or disease-induced anemia, a patient can be treated with red blood cell transfusions (36430).

Stem cell transplant a stem cell transplant (38240-38241) with bone marrow or peripheral blood stem cells may be performed when a patients bone marrow is damaged and cannot make red blood cells, white blood cells and platelets that the body needs.

Generally, medically necessary blood transfusions are a covered service under Part A and B of Medicare, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a Dallas, Ga.-based coding consulting firm.

While there are various methods of blood transfusions transfusion of homologous, autologous, or donor-directed blood Medicare coverage does not make a distinction between them.

According to Parman, aside from allowing coverage using 36430 and billing the procedure as incident-to, Medicare identifies other related procedures that can also be billed:

IV fluids for flush (J7030, J7040 and J7050).

Laboratory work for the type and crossmatch would be covered based on the clinical laboratory policies (86900-86906, blood typing; and 86920-86922, compatibility test each unit; immediate spin technique).

Payment may be made for the blood product (per unit) if the transfusion is homologous or perioperative blood salvage. The blood product is not covered if the transfusion is autologous or donor directed.

Blood components not subject to the three-unit blood deductible include Cryoprecipitate, P9012; Fibrinogen, P9013; Gamma globulin, P9014; RH immune globulin, P9015; Leukocyte poor blood, P9016; plasma, P9017, P9018; and platelets, P9019 and P9020.

When the blood is provided by a blood supplier, the supplier may not bill or receive direct payment from Part B in any setting for blood donation services (collection, processing, or storage of blood).