Oncology & Hematology Coding Alert

Question: Are there any codes that are appropriate for central venous access blood draw, central venous access declotting, and central venous access heparin now that APCs have taken over the hospital outpatient reimbursement?

Minnesota Subscriber

Answer: Ambulatory payment classifications (APCs) implemented in August impact hospital outpatient care much the same way diagnostic-related groups (DRGs) impacted hospitals inpatient care in the early 1980s. With the onset of APCs, oncology services were spared for the most part. Key considerations are that all services must be billed using a revenue code, descriptor of service, CPT or HCPCS code, date of service and charge.

CPT codes, if available, should be used when billing Medicare as they were used prior to APCs. Therefore, the same codes you used before would be appropriate.

Central venous device blood draws would fit into the same category as a simple venipuncture. Venipunctures are no longer a payable service with APCs because they are viewed as incidental to other procedures and are bundled into that charge. This would also apply to a central venous access device blood draw, which is considered an incidental procedure to the laboratory test.

Central venous device declotting is a billable procedure, and code 36550 (declotting by thrombolytic agent of implanted vascular access device or catheter) should be used along with the thrombolytic drug charge. Assuming central venous access heparin is the same as central venous access device flush with heparin, this particular charge depends on your state and Medicare intermediary. Follow the practice you used prior to APC implementation. In some states this is considered maintenance care and is not reimbursable. In others, code 90784 (intravenous therapeutic, prophylactic or diagnostic injection) can be used. If you are in a state that applies the latter, continue to use this charge as before with the heparin drug charge.

There are, however, always exceptions. With APCs in oncology, these exceptions are associated with intravenous administration and chemotherapy administration. In both of these cases, the HCPCS codes should be used: Q0081 for infusions other than chemotherapy; Q0083 for chemotherapy by other than infusion (i.e., IVP); Q0084 for chemotherapy by infusion; and Q0085 for chemotherapy by infusion and other method (such as IVP) except for administration of chemotherapy and intravenous infusions other than infusion.

All services must be assigned revenue codes, and these codes have changed with APCs. A summary of the revenue codes most commonly used in oncology includes:

636 All billable drugs, vaccines, and blood
products
331 or 335 Chemotherapy administration
260 IV administration
510 Injections with visit
280 Injections with chemotherapy
771 Vaccine administration
38x Blood product administration
333 Therapeutic radiation
510 Facility fees for visits

Finally, status codes have been assigned to all procedures. For a service to be considered payable, it must have a HCPCS or CPT code and be assigned an APC status indicator of S, T, V or X. S status represents significant APC procedures that are not subject to multiple procedure discounts; this includes administration of chemotherapy and IV infusions.

T status represents significant services that are subject to multiple procedure discounting, usually surgical procedures. V status represents facility costs associated with visits and billed on a per-visit basis. X status represents ancillary services billed on a unit basis, such as IV, intramuscular (IM) or subcutaneous (SQ) injections. Oncology departments must capture all V and T services provided in the cancer center because these services represent the support services provided for physicians.

This question was answered by Margaret Hickey, RN, MSN, MS, OCN, an independent coding consultant and former clinical director of the Tulane Cancer Center in New Orleans.