Oncology & Hematology Coding Alert

Question: We are a community cancer center that houses two physician practices and bills as a private practice. Our building is attached to a hospital, making it convenient to perform blood transfusions in our chemotherapy suite. We have been billing transfusion administration with 36430 (Transfusion, blood or blood components), but the billing office recently expressed uncertainty over whether we should bill for this service or if the hospital should report it. Who is correct?

Oregon Subscriber

Answer: It appears that the patients referred to the freestanding cancer center are hospital inpatients or outpatients, admitted to the hospital for treatment that includes a transfusion. Once the need for a transfusion is established, the patient is then routed to the cancer center to receive this service, potentially in an effort to increase patient convenience.

According to the Medicare Carriers Manual, Section 15022(B)(1, 2), if a patient is a hospital inpatient and is transported to a freestanding center for therapy, the technical component for the services cannot be paid to the freestanding facility. The patient will need to be discharged and readmitted, or the freestanding facility can receive payment from the hospital through prior contractual arrangements. In addition, blood transfusion services furnished to hospital Medicare patients by physicians and nonphysicians are Part A services. If complications associated with the transfusion occur with hospital inpatients or outpatients, the physician is generally instructed to code and bill for the services provided (e.g., critical care, consultation).

Sometimes blood transfusion services are administered in the clinic or office setting, and performed by the physician. In this case, 36430 (Transfusion, blood or blood components) may be covered by Medicare and other payers, if medical necessity is proven. In addition, when the transfusion is performed and monitored by nursing staff, is supervised by a physician and meets the requirements for "incident to" billing, Medicare will generally reimburse for this service performed in the office or clinic. Payer definitions and acceptance of incident to vary, so individual payer guidelines should be obtained.