Oncology & Hematology Coding Alert

Prepare early to defeat J9190 denials

Tired of being put through the wringer when it comes to ambulatory infusion pump claims? Get the inside scoop from fellow coders who share how they overcame the most troubling pump reporting hurdles.

1. Look to E Codes for Pump Costs

When you rent ambulatory pumps to patients, you may report E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), says Kathy S. Morrison, CPC, account manager, department of medicine with MedBest Medical Management Inc. in Syracuse, N.Y. You should report the code to the Durable Medical Equipment Regional

Carrier (DMERC). Code E0781 describes electrical pumps carried by the patient and used outside the office. 
 
Use E0779 (Ambulatory infusion pump, mechanical, reusable, for infusion eight hours or greater) and E0780 (Ambulatory infusion pump, mechanical, reusable, for infusion less than eight hours) for refillable nonelectric pumps carried by the patient. 
 
Remember: If your oncology practice does not own or rent its pumps, you cannot bill for them because there are no costs to recoup.

2. Don't Miss Maintenance and Supply Codes

Depending on the maintenance and supplies you provide, you may report A4221 (Supplies for maintenance of drug infusion catheter, per week [list drug separately]) and A4222 (Infusion supplies for external drug infusion pump, per cassette or bag [list drugs separately]).
 
Code A4221 is a weekly charge for supplies used for maintenance of the port of an epidural catheter. Include catheter site dressings and flush solutions not directly related to the drug infusion under A4221.
 
Code A4222 is used for the supply cost for each bag or cassette furnished to the patient. You may report these codes even if the oncologist also reports codes for initiation or refilling of the pump.
 
When you report the initial filling of a pump in the physician's office, look to infusion codes that describe the administration method and time. Example: Your office fills a pump for the first time for an intravenous infusion that will take more than eight hours. Report 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump).
 
A note in the CPT manual instructs you to see 96521-96523 for each additional pump maintenance and refill. For your ambulatory pump maintenance and refill, use 96521 (Refilling and maintenance of portable pump).

3. Prepare for the Most Common DMERC Troubles

If you contract with a supplier, it may take on the task of billing DMERC for the pump and supplies.
 
You will probably need to report the drugs to your regular Medicare carrier.
 
If you rent or own your pumps, you-ll be sending the equipment and supply claims to DMERC and the pump hookup and refills to Part B, says Tricia Katzberg, RHIT, CPC, CCS-P, with Bend Memorial Clinic in Bend, Ore. -You need a CMN (certificate of medical necessity) to send to DMERC,- she says. Sending claims to DMERC once per 30-day cycle works for her clinic.
 
Remember: You need a separate provider number to report to the DMERC, though this extra step should be eliminated when health plans allow you to use the new National Provider Identifier (NPI). All health plans will have to use these beginning in 2007-2008. (You can read more at www.cms.hhs.gov/apps/npi/01_overview.asp.)
 
To avoid denials, be prepared to pay special attention to other troublesome DMERC issues, Morrison says:
 
1. complete the paper CMNs and electronic CMNs correctly
 
2. post the ordering physician (who signed the CMN) to each line item
 
3. use the place-of-service code for where the patient lives (such as home or nursing home).

You should also be prepared to appeal denials for J9190 (Fluorouracil, 500 mg) when you provide the drug by pump in the office and in the home on the same day. DMERCs often deny the claim as duplicate because the DMERC knows you sent a claim for the same code to Part B, Morrison says.
 
Overcome this problem by discussing the service with your DMERC and Part B carrier. Plan to bolster your appeal with documentation and copies of the protocol that show it's medically appropriate to infuse the drug both ways on the same date of service, Morrison says.
 
Remember: Append modifier KD (Drug or biological infused through DME) to your drug codes to indicate administration through a DME infusion pump. CMS pays DME-administered drugs at a higher rate than those infused another way (such as injection).
 
Note: Stay tuned. Future issues will go more in depth on CMNs and proper pump reporting.