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 [...]