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Oncology & Hematology Coding Alert

How to Collect on Chemotherapy for Non-Cancerous Conditions

Published on Wed Jan 01, 2003

Inserting the wrong variable in the equation can result in mystifying denial patterns. If your oncology practice is plagued by denials for chemotherapy drugs and administration because the patient doesn't have a cancer diagnosis, you may be able to tweak your coding techniques and recover more if not all you'd like in the way of reimbursement.

Some coders believe that when delivering an antineo-plastic drug they should always use the chemotherapy administration codes regardless of the patient's diagnosis. The key to proper reimbursement lies in knowing when to match drug administration codes to diagnosis codes and when to match administration codes to the drug itself.

There are two basic ways in which your claims could be going astray, says Jennifer Darling, CORT, PA, billing and collections lead with the Center for Oncology Research and Treatment in Dallas. Your problem may be specific to your intermediary, which could be interpreting medical necessity and/or the primary indications for a drug inappropriately. Or, you could be submitting incorrect administration codes.

Chemo Codes Go With Cancer Diagnoses

Despite the precautions required and risks associated with chemotherapy drugs, Medicare and many other insurers will not pay for chemotherapy administration unless the diagnosis is cancer (ICD-9 140.0-239.9, V58.1). When employing antineoplastic drugs for non-cancer diagnoses, you are frequently limited to the lower-paying diagnostic or therapeutic infusion codes, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett.

A Medicare national coverage determination for chemotherapy administration states specifically that the "administration of antineoplastics to patients with a diagnosis other than cancer must be reported with codes 90780-90784, as appropriate."

The therapeutic or diagnostic infusion codes encompass:

  • 90780 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour

  • +90781 each additional hour, up to eight (8) hours

  • 90782 Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular

  • 90783 intra-arterial

  • 90784 intravenous.

    The code range for regular chemotherapy administration includes 96400-96450 (Chemotherapy administration), 96542 (Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents), 96545 (Provision of chemotherapy agent) and 96549 (Unlisted chemotherapy procedure).

    Chemo Codes Carry Higher RVUs for a Reason

    No matter why they are administered, all chemotherapy drugs are subject to the same level of coverage. If the physician is using a chemo drug regardless of purpose she must follow particular protocols with antineoplastic agents, such as watching for patient reactions during the infusion. This is why the chemo infusion codes carry higher RVUs (relative value units) than the nonchemo infusion codes, Darling says.

    For 2002, one hour of infusion therapy (90780) carries a nonfacility RVU of 1.06, while one hour of chemo infusion therapy (96408) has a nonfacility RVU of 1.47. At the time of publication, 2003 RVUs are not known, but Towle conservatively predicts that they will be unchanged or lower.

    Diagnoses Need Not Rule Out Specific Drugs

    You can get reimbursed for giving an antineoplastic drug to a patient without a cancer diagnosis, but you had better be prepared to memorize your local medical review policies (LMRPs), establish clear medical necessity and maybe even tussle with your carrier.

    As a general rule, remember that non-cancer diagnosis codes do not necessarily exclude drugs normally associated with chemotherapy regimens, Darling says. Approval and payment for the drug, on the other hand, depend heavily on the individual carrier and can be subject to state-by-state interpretations.

    For example, Cytoxan (Cyclophosphamide), a well-known chemo drug, is often used to treat rheumatoid arthritis (714.0). Blue Cross and Blue Shield of Georgia's LMRP explicitly lists rheumatoid arthritis as a covered diagnosis for Cytoxan (J9070-J9097). Systemic lupus (710.0) is another commonly covered indication for Cytoxan.

    As long as you have one of the covered diagnoses as your primary diagnosis, "third-party carriers do not usually have a primary diagnosis preference," Darling says. But, she adds, "Learning your state and carrier specifics like the back of your hand is even more important than the diagnosis."

    "In our clinic, we have made it a practice to call the carrier in advance, particularly with claims that we expect to cause problems," says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans.

    When Procedure Codes Take Precedence

    If you are dealing with a commercial, nongovernmental carrier, the diagnosis is secondary in importance to linking procedure codes, Darling says.

    In these circumstances, she notes, a J9XXX code must always be billed with 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) or +96412 (... infusion technique, one to 8 hours, each additional hour). Non-cancer drugs, which are defined by J codes that do not begin with "J9," must be billed with 90780 and 90781.

    When to Use Modifier -59

    One other way in which you could be raising red flags with payers is if you bill both chemotherapy administration for a drug like Cytoxan and nonchemotherapy administration for other drugs on the same patient for the same day. If this is the case, you need to append modifier -59 (Distinct procedural service) to the therapeutic infusion codes.

    Towle reminds readers always to use your modifiers on the less-expensive procedure since this is the one that will be reduced.

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