Oncology & Hematology Coding Alert

The billing rules for chemotherapy delivery systems can seem like so much tangled tubing - but master those fine distinctions between coverage rules for internal and external infusion pumps and you can keep your reimbursement flowing more smoothly. Medicare only covers infusion pumps that fall under the category of durable medical equipment (DME), which according to the Medicare Carriers Manual (Sect. 2100.1.A) means that "an item is considered durable if it can withstand repeated use, i.e., the type of item which could normally be rented." This means Medicare does not cover disposable pumps (like elastomeric pumps) and the drugs dispensed through them, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans. Coverage Varies by Pump Type Reusable external and implantable pumps are covered by Medicare, but different coverage and payment rules apply to the devices. Although both types of pumps receive benefits and coverage options, unique E codes apply to internal and external pumps. External pumps also contain two unique subcategories: stationary (meaning the pump typically does not leave the oncologist's office) and ambulatory (meaning the patient can easily take the pump home).

Medicare treats implanted pumps - which typically deliver chemotherapy intrathecally or epidurally - as DME. One of the primary differences is that more drugs are covered with external pumps than are covered with implanted pumps. For both internal and external pumps, remember the foundational rule: You bill for chemotherapy administration (96410-96423) or the use of infusion pumps (E codes) - but never both on the same day. Covered Drugs for External Pumps You cannot use chemotherapy administration codes for using infusion pumps at home (out of office); Medicare rules say that you can bill only for the cost of the drug itself. The following oncology-related drugs are covered for administration via external pump, even if the patient self-administers the drugs outside the office setting:

For continuous infusion over at least 24 hours  cladribine (J9065), fluorouracil (J9190), cytarabine (J9100-J9110), bleomycin (J9040), floxuridine (J9200), doxorubicin (J9000-J9001), vincristine (J9370-J9380) and vinblastine (J9360). Morphine and other narcotic analgesics administered to patients with intractable pain caused by cancer. These drugs may be administered in either an inpatient or outpatient setting, including hospice. Please note, however, that patients must also meet one of two additional conditions: 1) Patients have not responded to oral or transdermal pain medications, or 2) patients cannot tolerate oral or transdermal narcotic analgesics, according to Medicare guidelines. Codes Used With External Pumps Several categories of items and services should be billed in connection with external pumps. Oncology consultants typically include the following categories:

Rental for the pump itself
Rental for equipment used in connection with a stationary pump
Some supplies used [...]