Oncology & Hematology Coding Alert

In the March 2000 Oncology Coding Alert, Reader Questions, a reader asked about coding for intravenous antiemetics following a recent denial by a payer because, the payer said, an oral version of the anti-nausea drug should have been used first. The coding expert answering the question told readers that if they need to prove the medical necessity of using intravenous antiemetics, they should not be afraid to use ICD-9 poisoning codes to describe a patient's failure to respond to oral antiemetics.

This month we have a different perspective from another expert. Laurie Lamar, RHIA, CCS, CTR, CCS-P, a reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va. and member of the Oncology Coding Alert's editorial board, offers an opposing view regarding the use of poisoning codes.

Oncology practices should not use poisoning codes if the oral antiemetics were given to the patient as prescribed. According to the American Hospital Association's Coding Clinic for ICD-9-CM, the determining factor in using poisoning codes, 960-979, is the manner in which the substance was used.

ICD-9 makes a distinction between poisoning and adverse effects from drugs that were administered correctly. They make this distinction to facilitate data collection on adverse effects that occur after correct use and the extent to which adverse effects result from incorrect use.

The poisoning code is appropriate if you are coding poisoning or a reaction to the improper use of a medicationsuch as wrong dose, wrong substance or wrong route of administration.

An adverse effect occurs when a patient has an unexpected reaction to a drug that is correctly prescribed and administered. The code for the reaction should be sequenced first, followed by the appropriate code from the E930-E949 series, which for an antiemetic is E933.0 (antiallergic and antiemetic drugs).

Coders should ask themselves the following questions before they decide whether to code an adverse drug reaction or poisoning:

1. Is the condition due to drug, medicinal or
biological substance? If not, code the condition.

2. If the answer to question one is yes, did the patient take the correct medication exactly as it was
prescribed? If not, code for poisoning.

3. If the answer to question one is yes, did the patient also take either alcohol or a drug not prescribed by the physician? If not, code the condition. If the answer is yes, code for poisoning.

Often, however, the decision to use intravenous antiemetics following the use of oral antiemetics has little to do with an adverse reaction or poisoning. The decision is based on the patient's failure to respond to the oral drug. In this instance, neither an adverse reaction nor poisoning is the proper characterization.

When patients fail to respond to oral antiemetics and are given the drugs intravenously, practices should bill for both oral and intravenous antiemetics. If the payer denies one of the drugs, the practice likely will be paid following an appeal that includes chart notes that indicate the patient had breakthrough emesis on the oral antiemetics, resulting in the subsequent use of IV antiemetics.