Oncology & Hematology Coding Alert

Make this J9040 slip, and you'll report 15 times more units than you should.

The ABVD regimen for treating Hodgkin's disease may have been around since the 1970s, but the way you report the service to insurance companies has certainly seen some changes over the years. Get the proper HCPCS and CPT choices down pat with the tips and tactics below.

Capture Drug Dollars With These HCPCS Codes

"ABVD" refers to the first letters of the drugs used in the regimen, which include Adriamycin, bleomycin, vinblastine, and dacarbazine, says Melanie D. Kramer, CPC,certified clinic coder for Bozeman Deaconess Health Group in Bozeman, Mont.

Adriamycin:

Coded using J9000 (Injection, doxorubicin hydrochloride, 10 mg),Adriamycin is a brand name for generic chemotherapy drug doxorubicin, says Kramer, whose specialties include hematology and oncology. You also may see doxorubicin sold under the brand name Rubex.

Bleomycin:

Another chemotherapy drug, bleomycin is sold under the brand name Blenoxane and coded using J9040 (Injection, bleomycin sulfate, 15 units).

Vinblastine:

Marketed under names such as Velban and Alkaban-AQ, vinblastine is also a chemotherapy drug. Report it using J9360 (Injection, vinblastine sulfate, 1 mg).

Dacarbazine:

You may see this chemotherapy drug under the name DTIC-Dome. Your code choice will depend on the amount of drug used: J9130 (Dacarbazine, 100 mg) or J9140 (Dacarbazine, 200 mg).

Smart move:

Kramer has the benefit of working with infusion documentation sheets set up by regimen or cancer diagnosis. They show a combination of brand names and generic/chemical names. "I have the pharmacy ticket to verify, but ultimately it falls to the coder to have knowledge of the different drugs and their various names. If I am unsure, I look up the drugs," Kramer says. The HCPCS manual "Table of Drugs" allows you to look up a drug and get information such as additional names, the delivery method, and the HCPCS code, she says. Or she'll access an online database specializing in clinical information.

Fine Tune by Following an ABVD Example

For ABVD, the patient typically receives pushes of bleomycin, doxorubicin, and vinblastine. The patient also receives an intravenous infusion of dacarbazine. The oncologist will order the dosage based on the patient's body mass.

Example: A nurse administers the following to a patient with Hodgkin's disease (201.x, Hodgkin's disease):

• 18.9 units bleomycin, IV push, 9 minutes
• 47.25 mg doxorubicin, IV push, 5 minutes
• 11.34 mg vinblastine, IV push, 2 minutes
• 708.75 mg dacarbazine, IV infusion, 1 hour.

CPT solution: Assuming the one-hour dacarbazine infusion is your initial service, you should assign initial infusion code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for that service. (For more information on initial code choice, see "CPT Notes Bolster 'Initial' Code Choice" on page 19.)

For each of the three chemotherapy IV pushes in the example, you should report +96411 (Chemotherapy administration; intravenous, push technique, each additional substance/drug [List separately in addition to code for primary procedure]>). For most payers, you should report +96411 with a quantity of 3, but verify the correct reporting structure for your local commercial payers.

Watch for:The nurse also may administer an antiemetic with this regimen, so be on the alert for additional reportable drugs and administration services.

Round Up Units, Reel In Appropriate Pay

Before you can determine how many units to report for the drugs in the example, you need to understand the rules. You should calculate drug units based on the code descriptors and the amounts administered. According to Medicare Claims Processing Manual(MCPM), Chapter 17, Section 70 (www.cms.hhs.gov/Manuals):

• When you report a drug using a HCPCS code, you should enter units in multiples of the dosage in the HCPCS code descriptor. "For example, if the description for the code is 50 mg, and 200 mg are provided, units are shown as 4," the MCPM states. You divide the 200 mg administered by the 50 mg in the descriptor to arrive at the 4 units you report on the claim.
• When the dosage amount is greater than the amount in the HCPCS code descriptor, round up to determine the units. For instance, if the code descriptor indicates 50 mg and the nurse administers 80 mg, you should report 2 units.

Apply the Rules to ABVD Example

Dacarbazine: The descriptor for dacarbazine indicates you should report 1 unit for every 200 mg. The patient received 708.75 mg, so you should report 4 units of J9140, at 200 mg per unit.

Bleomycin: When you calculate the units for bleomycin, be sure to distinguish between the units you enter on the claim and the units referenced in the code descriptor: Injection, bleomycin sulfate, 15 units. The patient in the example receives 18.9 units of bleomycin, so you should report 2 units of J9040 on the claim:

Doxorubicin: The 47.25 mg of doxorubicin merit 5 units of J9000. The code descriptor indicates that you should report 1 unit for every 10 mg.

Vinblastine: The J9360 code descriptor indicates you should report 1 unit per mg. So for the 11.34 mg of vinblastine, you should report 12 units.

Documentation tip: Instruct clinicians to always document the precise dosage given for each patient encounter to support the medication and total units billed, says Lisa Martin, CPC, CIMC, CPC-I, consultant with Revenue Cycle Inc. in Austin, Texas. And when weight is an element of the dose calculation, ensure clinicians document the patient's weight on each date of service. An auditor could ask for a refund if your practice provides a weight-based dose without documenting that exact dates weight, Martin say's.