Oncology & Hematology Coding Alert

Most oncology practices absorb the cost of chemo-therapy supplies as inclusive with the administration. While this is sound thinking when seeking reimbursement from Medicare payers, practices could be leaving money on the table where commercial insurers are concerned.

If oncology practices obtain a provider identification number (PIN) from their durable medical equipment provider, there may be instances in which supplies can be reimbursed when caring for Medicare patients. Medicare guidelines are fairly clear about how chemotherapy supplies should be billed. Most supplies associated are bundled as part of chemotherapy administration (96400-96549).

Chemotherapy supplies that are included in the Medicare reimbursement for administration include, but are not limited to, needles, IV setup, gauze, syringes, butterfly set, cotton, tubing, tape, and intracatheters.

Any fees associated with the preparation of a chemotherapy agent should also be included in the service for the administration. Separate payment is not allowed for the infusion of saline, an antiemetic, or any other nonchemotherapy drug when administered at the same time as a chemotherapy infusion (96410-96412). If these services are performed sequentially of chemotherapy administration, oncology practices should bill 90780-90781 (therapeutic or diagnostic infusions).

Commercial payers tend to follow Medicares lead. But upon close examination, some practices will find that items such as needles and syringes (A4206-A4209) are often reimbursed by commercial payers. Whether these supplies are reimbursed by a commercial insurer varies by individual contract. Among items that many non-Medicare carriers pay for include:

A4750 blood tubing, arterial or venous;
A4450 surgical trays; and
J1642 Heparin.

Sometimes you can negotiate payment for surgical trays, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology-Hematology in Hooksett, N.J.

Commercial payers, especially managed-care organizations, generally reimburse less than Medicare for the same procedures. So, with oncology practices getting less but incurring the same costs, even small items such as individual supplies used during chemotherapy can take their toll on a practices bottom line.

The first step to getting paid for supplies by commercial payers is to include the items in the contract between payer and provider. By doing this, you will let the payer know what procedures will commonly be performed.

Go to your major payers to create a group of codes that are preapproved for payment for the average amount of these items, Klein says. Show them exactly what is being used so they can acknowledge the costs that they are asking you to swallow.

Klein and Towle say it is not unreasonable for commercial payers to acquiesce. For example, many will reimburse between $30 and $40 for surgical trays, which include needles, slides tubing, syringes, dressing, gauze and other items. Medicare clearly says these are not reimbursable.

Avoid Use of 99070

Towle and Klein warn against automatically assigning 99070 (supplies and materials, provided by the physician over and above those usually included with the office visit or other service rendered). This code was not intended to be a blanket code for all supplies. It should be used when a practice needs to prove that it was required to use more supplies than usual.

Heparin and Saline

Two chemotherapy-related supplies are sometimes covered by Medicare Heparin (J1642) and saline (J7030-J7051).

If Heparin is used to flush a port prior to administration of chemotherapy by an implantable pump, 96414 (infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump), most Medicare carriers consider this procedure to be bundled with the reimbursement provided fewer than 96414.

Medicare rules stipulate that administration of fluids for maintaining vascular access between courses of chemo-therapy at the same session is essential for chemotherapy administration and is not to be separately billed. This includes port flushes. If a practice can show, however, that the port flush is a distinct and separate service from the chemotherapy administration, Heparin can also be billed. The same general rule applies to the use of saline during chemotherapy. If saline was used prior to the administration of the chemotherapy agent, oncology practices are allowed to bill for the cost of saline.

Flushing of a vascular access port prior to the administration of chemotherapy is considered to be an integral part of the procedure and is not separately reimbursed. If a special visit is made to the physicians office for port flushing, 99211 (office or other outpatient visit) should be reported.

Separate payment for saline or other intravenous solution used for hydration with or without chemotherapy is allowed, says Susan Callaway, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C. However, any saline or intravenous solution used for the administration of a chemotherapy drug is considered by Medicare to be included in the reimbursement for the infusion of a chemotherapy drug.