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 be billed accurately, says Alice Ettinger, RN, MSN, CPNP, program coordinator for the Division of Pediatric Hematology-Oncology at St. Peters University Hospital in New Brunswick, N.J.

In the event that the patient experiences an adverse reaction to the drug, a higher-level E/M service may be used because the physician is now probably involved. The oncologist examine the patient and makes a medical decision.

If the patients reaction is not severe, the patient may remain in the office for several hours for monitoring. Because this monitoring will usually be provided by the nurse, the practice cannot bill for a higher level of E/M service. It is still only a 99211.

In addition, there should be evidence that the patient was monitored for side effects, especially if oral chemotherapy is prescribed and taken outside the office. If followup phone calls are made to monitor a patients reaction, these should be noted along with the patients response. Counseling that may occur during followup phone calls is not a reimbursable service because E/M services require face-to-face contact with the patient or family member caring for the patient.

Self-injectable Pen Administration

Interferon alfa-2A is often used alone or in combination with cytarabine, J9100-J9110. Confusion can arise as to the form in which Interferon alfa is provided, Ettinger says. The injection pen is used as a form of distribution and can be self-administered.

According to Giacomozzi, if practices prescribe the self-injectable pen, Medicare allows them to bill for an office visit (99211-99214) to teach patients how to use the pen. It also allows the practice to bill for the drug (J9213). This, however, is a one-time-only billing opportunity. Following this visit in which education is provided, the practice can no longer bill for any services related to the administration of self-injected Interferon alfa. From this point, Medicare considers the drug to be self-administered, which is obtained by the patient through prescription.

As always, proper documentation is important. The physician must document the reasons for administering Interferon Alfa. Indicating 205.10 (... without mention of remission) and 205.11 (... in remission) in the record should satisfy medical-necessity requirements, Ettinger says. Documentation does not need to be sent with the claim, but must be available for review.

The importance of documentation applies not only to Interferon alfa but also to the use of oral chemotherapy drugs and other course of treatment. For example, Ettinger says, Documentation should include laboratory results and evidence that the physician reviewed the lab tests that resulted in prescribing a drug or treatment course.

Bone Marrow Transplantation

Bone marrow transplantation is a likely treatment option in younger patients. In most cases, this procedure is done outside the medical oncologists office, which means the procedure itself is not billed by the practice. The billing responsibility falls on the physician who performs the transplant in another facility.

This does not mean, however, that the medical oncologist does not have claim to some reimbursement. At some point, a decision to pursue this course of treatment was made by the medical oncologist and discussed with the patient and family. Giacomozzi says, Oncology practices may be able to bill 99215 (established patient office or other outpatient visit).

Because 99215 represents the highest-level office visit, a practice must demonstrate that the code is warranted. She says, The biller should show that the decision was made to undergo bone marrow transplantation as well as documenting the additional time the doctor spent with the patient discussing the treatment.

The CPT manual supports this. It advises that counseling and/or coordination of care with other providers or agencies are consistent with the nature of the problems and the patients and/or family needs.

Physicians who perform the transplant should use 38240 (bone marrow or blood-derived peripheral stem cell transplantation;allogeneic) or 38241 (bone marrow or blood-derived peripheral stem cell transplantation; autologous).