Oncology & Hematology Coding Alert

Question: We have had Medicare denials for using Anzemet (dolasetron) as an intravenous premedication for adjuvant chemotherapy for treatment of a breast cancer patient. We have used V58.1 (chemotherapy) along with ICD-9 code 174.9 (breast [female], unspecified). We have been told we should have tried oral antiemetics first, and then used IV antiemetics only if these had failed. Any suggestions?

Anonymous Illinois Subscriber

Answer: According to the Medicare Carriers Manual, intravenous antiemetic drugs should be used when a patient fails to respond to oral antiemetic drugs. The coverage is subject to the rules of medical necessity. This means that an appropriate diagnosis should be coded to describe the patient's non-response to the oral drug. Coders should not be afraid to use poisoning codes to describe a patient's failure to respond to oral antiemetics. Many coders feel that to use a poisoning code, a diagnosis of poisoning must be present. Instead, any type of an adverse reaction to a drug would constitute as poisoning.

For example, if a patient has an adverse reaction to the oral antiemetic, two ICD-9 codes should be listed on the claim form:

1. 963.0The first code describes the adverse reaction to the drug. (Locate Antiemetic agents in the alphabetical list of drugs and chemicals table at the beginning of section two in the ICD-9 manual. The code for this substance under the "Poisoning" column is 963.0. Codes found in this column describe adverse reactions such as hypersensitivity or allergic reaction.)

2. E933.0The second code explains that the adverse reaction came from a drug correctly administered for therapeutic use.

E codes are not required but using them may eliminate questions from the insurance company. Not using an E-code leaves the reason for the poisoning questionable. When reviewing the different columns of choice for external-cause codes (E-codes), there are E-codes for an accident or accidental poisoning which means an accidental overdose of a drug, wrong substance given or taken, etc. Using E933.0 tells the insurance company that the poisoning was due to an adverse reaction to a therapeutic drug. E-codes complete the story.

Editors Note: The answer to this reader question is provided by Laurie Castillo, MA, CPC, president of American Association of Procedural Coders Northern Virginia Chapter and a consultant with Physician Coding & Compliance Consulting, a coding consulting firm in Manassas, Va.