Oncology & Hematology Coding Alert

These 3 steps will make a summary of medications.

You know oncologists infuse not only chemotherapeutic agents but non-chemotherapeutic agents as well. You must know how to report a variety of infusions. Before you become frustrated with the process, check out this example and handy chart that will simplify your claims.

Read This Infusion Scenario

You may read that your physician treated a patient with stage IIA non-small cell lung cancer. The patient had a surgical resection followed by four cycles of carboplatin/Taxol. Your physician now documents the patient has metastatic disease to the bone. The physician treats the patient with chemotherapy and non-chemotherapy medications. Chemotherapy was started with pemetrexed (Alimta^®) 500 mg/m2 and bevacizumab (Avastin^®) 15 mg/kg through an IV. Treatment was given every 21 days. The patient also received zoledronic acid (Zometa^®) 4 mg through an IV every 28 days. This also included infusions of palonosetron (Aloxi^®) 0.25 mg and dexamethasone 10 mg. The patient also had 500 ml of normal saline.

Break Down Medications Into 3 Steps

Step 1: The first step is to prepare a summary of the medications the physician ordered and administered. Note both the chemotherapy and non-chemotherapy medications administered. In the example above, you have:

• pemetrexed (Alimta^®), reported with J9305 (Injection, pemetrexed, 10 mg)
• bevacizumab (Avastin^®), reported with J9035 (Injection, bevacizumab, 10 mg)
• zoledronic acid (Zometa^®), reported with J3489 (Injection, zoledronic acid, 1 mg)
• dexamethasone, reported with J1100 (Injection, dexamethasone sodium phosphate, 1 mg)
• palonosetron (Aloxi^®), reported with J2469 (Injection, palonosetron HCl, 25 mcg)
• normal saline, reported with J7040 (Infusion, normal saline solution, sterile (500 ml=1 unit))-although you may not report this code at all.

Step 2: You need to have clear documentation for how much medication was ordered, how much was administered, the route by which the medication was given and the duration of each infusion. In the example above, you have:

• pemetrexed (Alimta^®) 500 mg/m2 ordered; 500 mg/m2 administered through IV
• bevacizumab (Avastin^®) 15 mg/kg ordered; 15 mg/kg administered through IV
• zoledronic acid (Zometa^®) 4 mg ordered; 4 mg administered through IV
• dexamethasone 10 mg ordered; 10 mg administered through IV
• palonosetron 0.25 mg ordered; 0.25 mg administered through IV
• normal saline 500 ml ordered; 500 ml administered through IV

Step 3: You'll need more information to understand the duration of each infusion. Let's say the duration was as follows:

• pemetrexed (Alimta^®) from 0900-1300 (4 hours)
• bevacizumab (Avastin^®) from 1110-1245 (1 hour 35 minutes)
• zoledronic acid (Zometa^®) from 0918-0948 (30 minutes)
• dexamethasone from 0900-0915 (15 minutes)
• palonosetron from 0915-0930 (15 minutes)
• normal saline from 0900-1300 (4 hours)

As an example of how you would record the summary of the medications administered, see Table 1. A table such as this may help you better visualize the therapy and coding required. Use the last column to record the administration CPT^® codes and quantities.

CPT^®: You Need to Code Every Infusion

The physician's progress note indicates the infusion therapy is to deliver chemotherapy. Therefore, the initial code should be selected for one of the chemotherapeutic medications. Report CPT^® code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the administration of pemetrexed disodium your physician administers over an hour.

Next, turn your attention to bevacizumab. The infusion lasted 1 hour and 35 minutes. For this infusion report CPT^® code +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 first hour and CPT^® code +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]) for the additional 35 minutes.  

Note: "In order to use an 'each additional hour code' of any kind, the infusion must last more than 30 minutes beyond the hour (or at least 31 minutes) to support it," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner of Pinnacle Enterprise Risk Consulting Services, LLC. 

For the non-chemotherapy infusions, report the following codes:

• You should report the 30-minute infusion of zoledronic acid with CPT® add-on code +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion of a new drug/substance, up to 1 hour [List separately in addition to code for primary procedure]). 

Don't forget to include the infusions of 0.25 mg of palonosetron (J2469) and 10 mg of dexamethasone (J1110) given over 15 minutes at separate times.

You would report this with two units of CPT^® add-on code +96375 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]).

Note: "An infusion of 15 minutes or less is reported as an intravenous (IV) push," Loya says.

According to CPT^® guidelines, when administering multiple infusions, injections or combinations, you should report only one initial service code, unless protocol requires that two separate IV sites must be used and is appropriately supported by the documentation or when the patient presents for two different encounters on the same day and the physician documents the reasoning for the second visit.

Therefore, your CPT^® codes should be as follows:

• 96413
• +96417
• +96415
• +96367
• +96375 x 2.

Check out "For Infusions, Primary Purpose - Not Medication Sequence - Matters Most" on page 45 to understand how to sequence your CPT^® codes.

Be Precise with Your Units for HCPCS Codes

Report the HCPCS codes for both the chemotherapy and non-chemotherapy medications.

To ensure payment for the entire amount of drug your physician administered, you need to report the accurate numbers of units for the medications. Because some drugs are quite expensive and may be considered toxic, oncologists have to follow treatment protocols and only a particular number of units of the drug may be allowed. This is where the medically unlikely edits (MUE) come into play. If you bill an excess of units, you most likely will receive a MUE denial, as the payer will recognize too large of a quantity of the drug was billed.

Pemetrexed: You should report 90 units of J9305 for pemetrexed as one unit of J9305 covers 10 mg of pemetrexed. The documentation supports 900 mg of pemetrexed administered, or 90 units of J9305.

Bevacizumab: Similarly, you need to calculate the units of J9035 for bevacizumab. You should submit 100 units of J9035 for 1000 mg of bevacizumab that was administered.

Dexamethasone and zoledronic acid: You should report one unit of codes J1100 and J3489 for every 1 mg of dexamethasone and zoledronic acid, respectively. Since your physician administers 10 mg of dexamethasone and 4 mg of zoledronic acid, you should submit 10 units of J1100 and 4 units of J3489.

Palonosetron hydrochloride: Lastly, one unit of HCPCS code J2469 reports 25 mcg of palonosetron hydrochloride. Since 0.25mg of palonosetron was administered, you would submit 10 units of J2469.

Saline: You do not report any HCPCS code for saline as this is incidental hydration. (Table 2 illustrates the codes and quantities from the above example).

Therefore, your HCPCS codes are as follows:

For pemetrexed and bevacizumab, you report the following J codes:

• J9305 x 90
• J9035 x 100

For the non-chemotherapy medications, you submit the following J codes:

• J1100 x 10
• J2469 x 10
• J3489 x 4

​

Here Are Your Final Codes

Here are the codes you should report for this example:

• 96413
• +96417
• +96415
• +96367
• +96375 x 2
• J9305 x 90
• J9035 x 100
• J3489 x 4
• J1100 x 10
• J2469 x 10