Oncology & Hematology Coding Alert

Oncology and radiology teams can now offer people with low-grade, follicular or transformed B-cell non-Hodgkin's lymphoma (NHL) a much improved quality of life with ibritumomab tiuxetan (Zevalin) - the first radio-immunotherapy treatment approved by the FDA for the treatment of NHL.

Zevalin represents a new kind of cancer killer - a monoclonal antibody with an extra kick of radiation attached that boosts its tumor-killing power. The new radioimmunotherapy uses the body's own defenses (the immune system) to fight cancer. Coders should understand that the new treatment is "part diagnostic and part therapeutic," says Sandy Smith, a coding specialist at Tristan Associates in Harrisburg, Pa.

Smith's clinic has discovered that evolving coding strategies will likely require the same close attention to detail that the treatment does. She says Zevalin has "only been approved in February of this year, and we did our first patient at the end of July."

Zevalin "is probably the first in a series," says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett. "I think we'll see more treatment options once this therapy gets established."

Monoclonal antibody therapy with Zevalin is administered by intravenous infusion, generally over the course of about a week on an outpatient basis. Delivery of the regimen depends on a coordinated team of oncologists, nuclear medicine physicians or radiation oncologists, nurses, pharmacists and technicians. However, Towle says, the treatment will require a lot of clear communication between the players to make sure the patient's care is handled correctly.

Coders need to understand that "coordination of care is absolutely critical" at all levels, stresses Paul DeLioa, CEO of Tristan Associates in Harrisburg, Pa., which is a Zevalin-ready clinic. "We have an oncology group in the same building as us, so we've worked in close partnership to develop guidelines for delivery of this therapy."

Although the mechanics of administering the Zevalin will happen in another department, the oncologist is still ultimately responsible for the care of the patient, Towle says. "Additionally, if there are problems, symptoms or side effects, those are still our issue."

Here's how it works. On the first day, the patient received an intravenous infusion of 250 mg/m2 rituximab (Rituxan, J9310), which takes several hours. The appropriate chemotherapy administration codes for this procedure are 96410 and 96412. The rituximab will allow for improved targeting of the cancer cells.

Following this infusion, the patient travels to a nuclear or radiation oncology facility to receive an imaging dose of indium-111 Zevalin (J9999 or A4661) over the course of about 10 minutes. The oncology coder will submit only for the Rituxan, while the hospital department, whether it is radiology or another department, will be billing for the scanning and the Zevalin, Towle says.

While Medicare will only reimburse for one scan, many private insurance companies may pay for two scans, says Byron Hare, a representative specialist with IDEC's reimbursement hotline.

On either day one or day two of the therapy (or, between 2 and 24 hours after the infusion of indium-111 Zevalin), whole body images are taken with a gamma camera. Additional images are sometimes taken again 48 to 72 hours later. The oncologist uses these images to chart the path of the radio-tagged drug in the body and to assess how well it is targeting tumor cells. The radiology department will bill for each biodistribution scan performed.

If the oncology team decides that biodistribution of the Zevalin is not acceptable by day six, the treatment cycle halts. Hare says that should the treatment be stopped at any time during the cycle, documentation and communication with Medicare or other insurance carrier is key to billing for the portions that have been accomplished so far. The therapeutic dose (see below) is the most expensive portion of the treatment.

About one week after the initial treatment day, if all has gone well, the patient returns for a second intravenous infusion of rituximab (250 mg/m2) followed by yttrium-90 Zevalin, the therapeutic portion of the regimen. As on day one, bill J9310 for the Rituxan and the appropriate administration codes, 96410 and 96412.

After receiving the Rituxan, the patient again proceeds to the radiation oncology facility, this time to receive yttrium-90 Zevalin administered via an intravenous infusion lasting about 10 minutes.

For free-standing diagnostic centers, two codes are associated with this part of the treatment cycle, DeLioa and Smith say. Radiologists will bill administration of the therapeutic dose with 79400 (Radiopharmaceutical therapy, nonthyroid, nonhematologic) and the radiation handling with 77790 (Supervision, handling, loading of radiation source). No imaging studies are necessary after this infusion, according to Medicare (PM AB-02-120).

The administration of Y-90 Zevalin does not usually result in infusion-related toxicities. However, as with many radioactive treatments, blood cell counts will be lowered. The period of lowered blood cell counts may occur as late as two months following treatment and may last for several weeks. The oncologist will perform blood tests weekly for at least 12 weeks after therapy. Therefore, you can expect to submit multiple instances of 85024-85025 (CBC) as part of the complete reimbursement picture for this new therapy, Towle says.

Finally, Towle says, during any of these visits, you may code for a pertinent E/M service (99211-99215), if such service is rendered.