Oncology & Hematology Coding Alert

Scoop: Here's the latest on what these changes mean for your office

The upcoming reimbursement cuts to chemotherapy drug and administration codes take effect in 2005, but there's no time like the present to get ready for these changes.

CMS' shift from the Average Wholesale Price to an Average Sales Price reduces payment for 32 chemotherapy drugs and administration codes in 2005, which could cost oncology practices a purported $500 million in 2005. Here's a breakdown of estimated, preliminary payment rates for commonly used drugs and codes, according to the American Society of Clinical Oncology (ASCO).

Follow Guidelines When Reporting Rituximab

When your oncologist or nurse administers Rituximab, you should assign J9310 (Rituximab, 100 mg) for the drug, says Lisa C. Wood, office manager at Cancer Center of the Piedmont in Danville, Va.

You can expect to lose nearly $25 a pop when you report J9310, which drops from $438 to $413. Oncologists usually give Rituximab to patients with B-cell non-Hodgkin's lymphoma or leukemia whose cancers have not responded to other chemotherapy regimens.

Most Medicare payers, such as Empire Medicare Services in New York, require that your oncologist administer the drug through intravenous infusion, not the push technique, if you operate out of an outpatient setting.  

This means when you report J9310, you will likely assign 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) for the first hour, and +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]) for one to eight hours, Wood says.

Warning: CMS began to scrutinize the coding and billing of Rituximab earlier this year after it reviewed 100 claims, finding that 55 percent had been inappropriately billed, according to CIGNA Healthcare Medicare Administration. And with your practice standing to lose $25 for each J9310 billed next year, you don't want to lose even more because you incorrectly reported the code.

What to do: When you assign J9310, make sure you follow these coding and documentation guidelines:

1.  The patient has finished a "front line" or initial treatment of chemotherapy. Medicare pays for Rituximab when used for relapsed or refractory cancers. Payers may also reimburse one course of Rituximab during initial treatment if the physician administers in combination with another anti-cancer drug.

2. The cancer should be CD20 positive, which Medicare requires in the treatment of refractory different types of non-Hodgkin's lymphoma and leukemia.

3. Documentation records appropriate dosage. Generally, Medicare carriers require oncologists to give Rituximab in 375mg/m2 weekly doses for four weeks.

4. You must report a covered diagnosis. The best way to ensure that you're listing an appropriate ICD-9 code is to check with your insurer.

For instance, Medicare carrier HGSAdministrators would accept a physician diagnosis of 202.43 (Leukemic reticuloendotheliosis; intra-abdominal lymph nodes). But, if you submitted 174.x (Breast cancer) as a diagnosis code, HGSA would deny your claim - the insurer doesn't accept this code for Rituximab.

Pick IV Infusion Codes for Carboplatin

If your oncologist provides the anti-cancer drug Carboplatin (J9045) during chemotherapy administration, you'll get about $8 less per charge to Medicare payers. Oncologists often use Carboplatin to treat patients with ovarian (183.0) or kidney cancer (189.0).

Medicare now pays about $132 per 50-mg dose. But starting in 2005, you can expect to receive $124 for the same dose. Typically, oncologists or nurses administer Carboplatin (or Paraplatin) using IV infusion (for example, 96410, Chemotherapy administration, intravenous; infusion technique, up to one hour), says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent oncology coding consultant based in New Orleans

Rely On 90780-90781 to Report Pegfilgrastim

Oncology practices will also lose reimbursement for non-chemotherapy drugs, such as Pegfilgrastim (J2505, Injection, pegfilgrastim, 6 mg) and Filgrastim (J1441, Injection, filgrastim [G-CSF], 480 mcg). For J2505, payment will be $2,132, down from nearly $2,300. And J1441 will bring in $251 a dose instead of the $267 you get now.

Physicians use pegfilgrastim and filgrastim to increase the number of a patient's white blood cells. Heads-up: You should report the physician's administration of these drugs using non-chemo codes 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 (... each additional hour ...).

Remember That Administration Fees Will Drop

In addition to drug reimbursement, your payment for administration codes (96400-96549; 90780-90788) will drop as well, even though Medicare recently increased these codes' RVUs.

The problem is that CMS is reducing the transitional add-on payments physicians got this year from 32 percent to 3 percent.

For example, 96408 (Chemotherapy administration, intravenous; push technique) rose from $37.52 in 2003 to $154.76 in 2004, but will fall to $122.96 in 2005. Similar dramatic rises and falls affect 90780, which rose from $42.67 to $117.79 but will fall to $92.90, and 94610, which rose from $59.22 to $217.35 but will fall to $171.75.