Oncology & Hematology Coding Alert

Care plan options for chronic myeloid leukemia (CML), 205.1, include commonly used procedures such as bone marrow transplantation and a variety of chemotherapy drugs. On the surface, these procedures may seem straightforward, but each one includes coding twists that could lead to errors.

There are three main treatment options for CML oral chemotherapy, self-injected pen and bone marrow transplantation.

It is essential to have a firm understanding of the type of chemotherapy being used, which would determine whether an administration code is applicable, says Nancy Giacomozzi, office manager for P.K. Administrative Services, a medical billing agency based in Lakewood, Colo., which serves oncology practices.

Unlike other billable drugs, oral anticancer drugs are not submitted with HCPCS J codes. They should be sent to your durable medical equipment regional carrier (DMERC) using their National Drug Code (NDC). The NDC System was originally established as an essential part of an out-of-hospital drug reimbursement program under Medicare. The NDC serves as a universal product identifier for human drugs. For example, to bill Busulfan, a commonly used oral chemotherapy drug, oncology practices must provide the NDC number 00173-0713-25 to their DMERC.

In addition, billing for oral chemotherapy must include the following information on the HCFA-1500:

Item 17 must contain the name of the physician or other practitioner licensed to prescribe the oral cancer drug;

Item 17A must contain the unique physician identification number (UPIN) for physicians or the surrogate UPIN NPP000 for practitioners;

Item 21 or Item 24E must contain the ICD-9 code of cancer for which the patient is receiving the drug;

Item 24D must contain the NDC number for the oral cancer drug (instead of a HCPCS code);

Item 24F must contain the charge;

Item 24G must contain the number of units dispensed. Each tablet or capsule is equal to one unit; and

Item 33 must contain the supplier name and billing number issued by the National Supplier Clearinghouse.

It is also important to remember that coding for chemotherapy administration, 96549 (unlisted chemotherapy procedure), is not permitted when oral chemotherapy is concerned. There is no specific code for the administration of oral chemotherapy.

Oncology practices, however, can bill for evaluation and management (E/M) services related to dispensing the drug in the office. Normally, the nurse will give the tablet to the patient, provide counseling and answer questions. In this instance, bill for a nurse-only visit, 99211 (office or other outpatient visit). But documentation must show that the nurse also evaluated the patient in order to support this charge, Giacomozzi says.

Documentation is necessary to ensure that the patient record supports the items billed, and to establish the form of administration and variety of the drug so that services can [...]