Oncology & Hematology Coding Alert

Not all anti-emetics are alike, and they should not be coded as such. Ondansetron is a drug that is indicated for use with chemotherapy drugs that are classified as highly emetogenic, causing nausea and vomiting. Oncology coders must know which drugs correspond with billing for Ondansetron (J2405, Q0179) to get adequately reimbursed. Coders should become familiar with the documentation criteria required when the drug is used with low emetogenic chemotherapy, as a first-line treatment (first drug used) or when used in its oral form.

Reimbursement becomes a problem with private insurance companies and HMOs, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinical director at the Tulane Cancer Center in New Orleans. They may have a pecking order in their formulary that requires oncologists to use other specific anti-emetics before Ondansetron can be used.

Some carriers require oncology practices to first use oral Ondansetron or a less expensive anti-emetic drug and for the patient to be unresponsive to these drugs before IV Ondansetron is covered.

Get Paid for IV Administration

When intravenous (IV) Ondansetron is used to combat nausea, code J2405 should be used to describe the drug, and 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the infusion of the anti-emetic. Medicare requires these codes be included on the same claim form as the administration (96410-96412 infusion technique, one to eight hours, each additional hour [list separately in addition to code for primary procedure]).

Intravenous Ondansetron is generally covered when administered on the same day as the following high-toxicity drugs:

Cisplatin J9060-J9062
Cytarabine J9100-J9110
Mechlorethamine J9230
Cyclophosphamide J9070-J9097
Doxorubicin J9000-J9001

Using the correct codes associated with these drugs is important because they provide the strongest evidence of medical necessity, says Phyllis Klein, who specializes in oncology coding and is president of P.K. Administrative Services, a medical billing agency in Lakewood, Colo.

Medicare also allows coverage in situations in which the patient has a history of not responding to standard treatment for nausea and vomiting associated with chemotherapy. This type of claim would be filed the same way. For example, when a patient returns to the office days after chemotherapy was given with symptoms of nausea, the payer is likely to reimburse for IV Ondansetron even though it did not occur on the same day as the chemotherapy. The payment is based on the use of highly emetogenic chemotherapy just days before, Klein says.

Coders should also be aware that separate payment is not allowed for the infusion of saline, or any other non-chemotherapy drug administered under 90780 and 90781 (each additional hour, up to eight hours [list separately in addition to code for primary procedure] [use 90781 with code 90780]) when given simultaneously to chemotherapy infusion. Separate payment is allowed for these two services on the same day when they are provided sequentially rather than at the same time.

Carriers normally require that Ondansetron be provided on the same day as chemotherapy. If it is administered concurrently with the chemotherapy, separate payment is not allowed. However, reimbursement is possible if it is provided sequentially to the chemotherapy administration. Oncology practices should use modifier -59 (distinct procedural service) to indicate when 90780 and 90781are administered sequentially rather than contemporaneously with 96410, 96412 and 96414. In addition, the medical record should note the start and stop time of both Ondansetron and the chemotherapy drug, Hickey says.

Getting Paid for Oral Ondansetron

If oral Ondansetron, Q0179, is required as the first-line treatment or to prevent nausea, additional rules apply. Oral anti-emetics are, however, covered by Medicare when used as part of a chemotherapy regimen, provided the drug is administered by a licensed physician or ordered by him or her.

Medicare specifies the following requirements:

Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within two hours of the administration of the agent and may be continued for a period not to exceed 48 hours from that time.

The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the IV anti-emetic drugs that would have been administered at the time of the treatment.

In specific cases in which a chemotherapy agent is used that causes severe toxicity, Medicare will allow the use of an IV anti-emetogenic agent in the office the day of the chemotherapy and as a subsequent course of an oral anti-emetic agent as specified below to be sent home with the patient. In these situations, we expect medical records to be kept in the office to justify medical necessity.

The claim form should include Q1079 to indicate the drug. It is not necessary to use 90780 because it is administered orally. Code 96410 and the J code (drug code) describing what was used on the same day should be included on the claim form that is used to bill for Ondansetron.

Cancer is the Primary Diagnosis Code

Medical oncology practices can run into problems if they do not provide the proper documentation, which includes the correct diagnosis codes proving the drug was used appropriately.

Billing for IV or oral Ondansetron may include the malignant neoplasm codes (140-208.9) as the primary diagnosis code. Depending on the payer, V58.1 (chemotherapy, encounter or admission), which describes a chemotherapy encounter, can be used as a secondary diagnosis, or 787.0 (nausea and vomiting), which indicates nausea, can also be used. Code V58.1 can be replaced by more accurate CPT codes. For example, 787.0 is an appropriate secondary diagnosis code despite not describing the visit as a chemotherapy encounter. Carriers will understand that the administration of Ondansetron was part of a chemotherapy-related visit if 96410 is used with 90780 and J2405 on the claim.

These codes clearly indicate to carriers that Ondansetron was part of chemotherapy administration and should result in proper reimbursement.

Practices can use Ondansetron as a prophylactic to prevent the onset or decrease the severity of nausea because chemotherapy drugs such as Cisplatin will likely cause nausea. This inhibits practices to use 787.0.

If Ondansetron is used as a prophylactic, then the primary cancer diagnosis and secondary V58.1 are the correct codes to use, Hickey says.