Oncology & Hematology Coding Alert

And 'push' codes now include infusions of only 15 minutes or less

Good news, oncology coders: Your wait is over for CMS to clarify some confusing G code issues - at least for now.

The Centers for Medicare and Medicaid Services released Transmittal 148 on April 15 to clear up coding gray areas surrounding the new infusion and push G codes. Here are the five take-away points from the clarification, as well as the one notable omission:

1. A 'Push' Is Now 15 Minutes or Less

The original guidelines in CMS Transmittal 126 defined an intravenous or intra-arterial push as "an injection/infusion of short duration (i.e., 30 minutes or less) in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient."

Oncologists complained that an infusion is not a push, and consequently coders should not have to report it as such. "A push is a push," agrees Linda Gregory, business office manager for Oregon Hematology Oncology Associates PC in Portland. Including infusions in the push codes feels fraudulent from a coding perspective, she says.

Benefit: Now that CMS has defined a push as 15 minutes or less, you can report an infusion code - which reimburses higher - for any infusion over 15 minutes, says JoAnn Guay, CPC, with Shenandoah Oncology Associates in Winchester, Va. This means better revenue than before, when you had to report a lower paying push code for all infusions up to 30 minutes.

Continuing problem: Including infusions in push codes is still a flawed system because it prevents you from recouping adequate reimbursement for an infusion lasting less than 15 minutes. For example, "our anti-medics that we give prior to chemotherapy - they're dripped - and they may only take 10 minutes," Gregory says. "But instead of being able to use the infusion code, we have to use a push code - and we didn't push it."

2. G0350 Is Billable Only Once per Encounter

In CMS' original guidelines, the agency did not limit your G0350 (Intravenous infusion, for therapeutic/diagnostic [specify substance or drug]; concurrent infusion [list separately in addition to code for primary procedure] report only once per substance/drug regardless of duration, report G0350 in conjunction with G0345) billing for concurrent infusions. This issue needed clarification because coders could read the descriptor to mean you could bill the code twice, Guay says. And some oncology practices, in fact, were reporting a unit of G0350 for each concurrent drug.

New rule: Medicare will allow payment now for "only one concurrent infusion per patient per encounter." In addition, you cannot use modifier -59 (Distinct procedural service) to receive payment for a second unit of G0350 unless the oncologist provides the service "during a second encounter on the same day with the patient." And such a claim must include supporting documentation to justify medical necessity.

3. Initial Code Is Primary Reason for Encounter

The new transmittal reclarifies the original CMS guideline that the initial infusion code you report should be the code that "best describes the key or primary reason for the encounter" - and you should always report this code first "irrespective of the order in which the infusions or injections occur."

4. G Code Guidelines Apply for CMS in 2005

The CMS transmittal merely restates that the agency is not waiting to implement these guidelines, even though the CPT coding rules will remain unpublished until the 2006 CPT manual comes out.

5. Correction: G0346 Is for Hydration Not Concurrent With G0359

The original guidelines in Transmittal 129 incorrectly instructed coders to "report G0346 to identify hydration furnished concurrent with G0359." This statement confused coders and carriers alike.

Bottom line: You can report G0346 (Intravenous infusion, hydration; each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) only when the oncologist orders hydration administration that is not concurrent with G0359 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug).

Major omission: Although CMS clarified several coding gray areas, the agency notably offered no solution for how to code a concurrent chemotherapy infusion. There is a code (G0350) for a concurrent therapeutic/diagnostic infusion, but oncology coders still badly need a code to report concurrent chemotherapy, Gregory says.