Oncology & Hematology Coding Alert

Assigning J9999 makes all the difference

If you want to get paid for giving patients recently approved colorectal cancer drugs Erbitux and Avastin, you should use J9999 for both drugs, and report the chemo administration with 94610 and 94612.

The Food and Drug Administration (FDA) just approved ImClone's Erbitux, which oncologists use to treat patients with EGFR (epidermal growth factor receptor) or metastatic colorectal cancer (153.0-153.9 and 154.0-154.8).

Physicians can also use the drug for patients who are intolerant to Irinotecan (J9206)-based chemotherapy. By contrast, the FDA-approved Avastin, developed by Genetech, targets first-line, or previously untreated, colon or rectal cancer (153.0-153.9 and 154.0-154.8).

Assign J9999 for Both Drugs

Oncologists administer the antineoplastic drugs Erbitux and Avastin through intravenous chemotherapy infusions.

Therefore, you should use unlisted chemotherapy drug code J9999 (NOC, antineoplastic drug), not J3490 (Unclassified drugs), to bill the drugs, says Debra Seyfried, CPC, CMPE, administrator at Charleston Cancer Center in South Carolina.

Also, you should supply the drug's name and dosage in Box 19 of the CMS-1500 form, or in the electronic claim's comment field.

For instance, you would write on the form that the physician used 600 mg of Erbitux.

Payment for the drugs varies by carrier. For instance, TrailBlazer Health Enterprises, the Medicare carrier for Texas and a number of other states, pays $653 for 100 mg of Avastin, say David Davis, CPC, medical policy analyst with iHealth Technologies in Atlanta.

The carrier is reimbursing Erbitux at $547 for 100 mg. The drug's fee may vary by locality, so check with your local carrier for specific payment rates.

Code the Chemo Technique

To code the chemotherapy administration of these new drugs, you should know that the physician must administer the new drugs by intravenous infusion, according to Medicare guidelines.

Therefore, when the oncologist provides either drug for up to one hour, assign 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour), Davis says. Nationally, Medicare reimburses chemotherapy administration code 96410 at $230.

If the infusion lasts more than one hour, but less than eight, report +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]), Davis says.

Example: The physician or nurse should infuse 400 mg/m2 of Erbitux for more than 120 minutes at a minimum of 5 ml a minute. To report this administration, you would submit 96410-96412. This coding combination represents two hours of infusion, according to Empire Medicare Services of New York.

Important: Because both Erbitux and Avastin treat colon or rectal cancers, you should select the appropriate ICD-9 code from either the 153.0-153.9 (Malignant neoplasm of colon) or 154.0-154.8 (Malignant neoplasm of rectum, rectosigmoid junction, and anus) series.