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Oncology & Hematology Coding Alert

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Report Bilateral Excisions? CMS Wants to Pay You Less

Published on Mon Jun 20, 2005

Plus: A G0354 reporting tip you can't afford to miss

CMS has been hard at work coming up with a bevy of new rules for oncology coders. We'll help you wade through your new code options and payment rules so you can capture the reimbursement you deserve.

Adjust Your Bilateral Fee Expectations

Breast lesion excision codes 19120 and 19125 and eye lesion and biopsy codes 67810, 67840 and 67850, among others, now have a bilateral surgery indicator of 1, meaning the 150 percent payment adjustment applies for bilateral procedures - you get paid the lower of the actual cost or 150 percent of the value of one code. (See the rules on page 143 of the Medicare Claims Processing Manual at www.cms.hhs.gov/manuals/104_claims/clm104c23.pdf.)
 
Each of these formerly had an indicator of 0, meaning the 150 percent adjustment did not apply - you would receive the lower of the actual cost for both or 100 percent of one code. Snag: If you were reporting modifier -59 (Distinct procedural service) for these procedures and getting 100 percent reimbursement for each surgery, the bilateral changes could mean you can expect less money for these services. Keep an eye on your local payer's guidelines to see how it wants you to report these services.
 
You can see the full list of changes to July's 2005 fee schedule update at www.cms.hhs.gov/manuals/pm_trans/R558CP.pdf.

Counsel Smokers? Try These New Codes

You've also got two new G codes for tobacco cessation counseling under July's 2005 fee schedule update. To report these new codes, the patient must receive information beyond your typical E/M. Medicare will cover two attempts per year, with a maximum of four sessions each. Code G0375 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) has a miniscule nonfacility PE RVU of 0.09, and G0376 (...intensive, greater than 10 minutes) has a nonfacility PE RVU of 0.18.
 
You can find the details at www.cms.hhs.gov/manuals/pm_trans/R36NCD.pdf and www.cms.hhs.gov/manuals/pm_trans/R562CP.pdf. Note: You also have older Category II CPT codes for smoking assessment and counseling, but these typically don't offer any reimbursement.

Test Your New ICD-9 Knowledge

Starting Oct. 1, 2005, you'll be able to report three new diagnosis codes for genetic testing and counseling:

  • V26.31 - Testing for genetic disease carrier status
  • V26.32 - Other genetic testing
  • V26.33 - Genetic counseling.

    Don't miss: Once these new codes go into place, V26.3 (Genetic counseling and testing) will be invalid.
     
    More changes: You now report volume depletion for dehydration, but starting in October physicians will have to distinguish between unspecified volume depletion (276.50), dehydration (276.51) and hypovolemia (276.52).
     
    The new codes should help oncologists track dehydration specifically.
     
    You can check out the full list of proposed ICD-9 codes in the May 4, 2005, Federal Register, online at www.access.gpo.gov/su_docs/fedreg/frcont05.html, starting on page 23591.

    Delete G0354 Bundling Worries

  • CMS announced it will revoke five controversial edits governing drug administration code G0354 (Each additional sequential intravenous push). The National Correct Coding Initiative (NCCI) version 11.1, implemented April 1, bundled G0354 with five codes:
     

  • G0345 - Intravenous infusion, hydration;  initial, up to one hour
     
  • G0347 - Intravenous infusion, for therapy/diagnostic; initial, up to one hour
     
  • G0357 - Intravenous, push technique, single or initial substance/drug
     
  • G0359 - Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug
     
  • G0361 - Initiation of prolonged chemotherapy infusion (more than eight hours), requiring use of a portable or implantable pump.

    But NCCI version 11.2, which took effect July 1, will delete those edits retroactive to April 1. You're supposed to be able to bill an administration code for each bag you hang and each drug you give, so these edits run counter to that philosophy, says Andrea Peters, infusion billing manager with Texas Hematology/Oncology in Dallas.
     
    Strategy: Until that change, use modifier  -59 "to indicate that there was a separate sequential infusion of a different drug or the same drug at a different time," CMS says. Or you can just wait until after July 1 to submit claims from May or June, and the carriers won't apply the edits at all.
     
    Read Up on Abarelix Change

    Report J0128 (Injection, abarelix, 10 mg) for a prostate cancer patient, and Medicare just might pay. Starting March 15, 2005, CMS extended national coverage for Abarelix for palliative treatment in patients with advanced prostate cancer - but only under a long list of very specific circumstances.
     
    Good news: You can code the Abarelix on the same day as chemo and get reimbursed for both. Get all the details at www.cms.hhs.gov/manuals/pm_trans/R34NCD.pdf.

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