Oncology & Hematology Coding Alert

Assigning the correct diagnosis pointers is crucial for a successful claim.

Choosing the appropriate codes for your case is an important step, but it isn't the only step toward reimbursement. You have to know how to apply those codes to your claim form, as well. Use the following scenario as an example of how to represent your carefully chosen codes on a claim.

Scenario: Suppose a patient presents for chemotherapy. She completes the ordered chemotherapy infusions, but suffers from nausea and vomiting as a complication during the chemotherapy encounter. The physician orders hydration as a therapeutic infusion at the same encounter. You need to determine which diagnosis codes to report and which CPT Codes and HCPCS Codes to tie those ICD-9 codes to.

First, Determine Proper ICD-9 Order

Because the patient presented for chemotherapy, your first-listed ICD-9 code should be V58.11 (Encounter for antineoplastic chemotherapy). Next, you should list the relevant neoplasm code(s). Then list the codes for the complications. In this case, report 787.01 (Nausea with vomiting). Finally, you should include "E933.1 (Adverse effect of an antineoplastic and immunosuppressive drug correctly prescribed and administered) as the last diagnosis code. This E code describes the reason for the nausea/vomiting," explains Janae Ballard, CPC, CPC-H, CPMA, CEMC, PCS, FCS, coding manager for The Coding Source, based in Los Angeles.

Example: If we add to the scenario that the patient has a neoplasm in the upper lobe of her lung (162.3, Malignant neoplasm of upper lobe, bronchus or lung), then on a CMS-1500 claim form, your diagnoses would appear in field 21 ("Diagnosis ...") as:

1. V58.11

2. 162.3

3. 787.01

4. E933.1

Next, Point to the Proper Chemo Codes

Choosing the order for the ICD-9 codes is only part of successfully applying diagnosis codes to your claim. You also need to apply the proper diagnosis pointer to the CPT and HCPCS codes you report.

Chemotherapy: For the chemotherapy infusion codes, Ballard states the appropriate diagnosis codes would be:

On a claim form, the order of the diagnosis codes does matter, Ballard says. ICD-9 guidelines indicate that V58.11 should always be the primary code when the encounter is for chemotherapy administration alone.

Support: ICD-9 official guidelines (section I.C.2.a) tell you that when the patient presents solely for chemotherapy, you should report V58.11 first, and then report the malignancy as a secondary diagnosis. (Guidelines are available from www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines.)

Don't miss: You should link the diagnosis codes (V58.11 and the neoplasm codes) to both the chemotherapy administration (CPT) and drug (HCPCS) codes, says Ballard.

Example: Assume the example patient is being treated with a 30-minute IV infusion of gemcitabine (J9201, Injection, gemcitabine hydrochloride, 200 mg) followed by a 45-minute IV infusion of cisplatin (J9060, Injection, cisplatin, powder or solution, 10 mg).

Your CPT codes should be 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the gemcitabine administration and +96417 (Chemotherapy administration, intravenous infusion technique; each additional sequential infusion [different substance/drug], up to 1 hour [List separately in addition to code for primary procedure]) for the cisplatin administration.

On the claim, you should link the diagnoses to the CPT and HCPCS codes. On the CMS-1500 form, the codes we've assigned so far would appear as follows:

Finally, Decide How to Apply Hydration Codes

You aren't finished yet. The patient also received a medically necessary, ordered infusion for hydration, which you may report separately.

Take note: The diagnosis codes assigned for the hydration infusion ordered to treat the nausea and vomiting would be the following, Ballard says:

• First: 787.01
• Second: E933.1.

"The order of the diagnosis codes does matter; the Official ICD-9 Guidelines advise that the adverse reaction (nausea/vomiting) is to be coded first and the E code is coded second," Ballard says. You'll find the relevant guidelines in section I.C.19.c.

Next step: "These diagnosis codes need to be linked to both the [hydration] infusion code(s) and the code(s) for the fluid administered (normal saline, etc.)," Ballard says. "Many insurance companies will not pay separately for fluids when they are billed on the same claim as a chemotherapy infusion." So to help support medical necessity, you must link the hydration codes to the appropriate diagnosis codes. "It will show that the fluids were given for the adverse effect of chemotherapy, not as part of a chemotherapy regimen," she says.

CCI rule: Medicare's Correct Coding Initiative (CCI) policy manual states, "Hydration concurrent with other drug administration services is not separately reportable" (chapter 11, section B.5). On the other hand, "If therapeutic fluid administration is medically necessary (e.g., correction of dehydration, prevention of nephrotoxicity) before or after transfusion or chemotherapy, it may be reported separately" (section B.4). (You may download the manual at www.cms.gov/NationalCorrectCodInitEd/).

Example: Suppose the physician ordered an infusion of normal saline (J7030, Infusion, normal saline solution, 1000 cc) for the patient in the example. The infusion lasted one hour and twenty minutes, so you should report+96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]) and link the codes as follows:

Lesson learned: "Diagnosis codes are used to describe the reason a service/procedure was performed. It would not be appropriate to link all the diagnosis codes to all CPT/HCPCS codes billed on the claim because it would not tell an accurate story of what events took place during this encounter," Ballard explains.

When you separate the diagnosis codes and link them to the appropriate CPT and/or HCPCS codes, "Medicare or a commercial insurance will be able to tell that the patient received their ordered chemotherapy and then developed a reaction," Ballard says. With this knowledge, the payer should see the medical necessity for the reported services and supplies, and should pay the claim appropriately.