Oncology & Hematology Coding Alert

Question: Many of our patients become anemic following chemotherapy administration. During a separate episode of care, the physician orders Procrit and the nurse administers the ordered amount.

Our interpretation of the AMA CPT and CMS guidelines is that the administration of biological response modifiers (such as Procrit) should be coded and charged as chemotherapy administration with codes 96401 and 96402. Is this correct?


California Subscriber


Answer: You should report the Procrit administration with 90772 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) instead of 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) or 96402 (... hormonal anti-neoplastic).

CPT Changes 2006 does say to use chemo admin codes for -substances such as monoclonal antibody agents and other biologic response modifiers.-

You will typically see Procrit classified as a glycoprotein or an acid glycoprotein (a carbohydrate and protein compound), though you may sometimes see Procrit classified as a biological response modifier.

CMS instructions: Kansas Medicare instructs you to -report code 90772 or 90773 (and 90775 when appropriate) for the injection procedure when the patient is not on dialysis.- (See www.kansasmedicare.com/Part_B/LMRP/policies/ASyntheticErythropoietinandChronicRenalFailureCRF.htm.)

Don't forget: Report the Procrit with J0885 (Injection, epoetin alfa [for non-ESRD use], 1,000 units), paying close attention to units.

For more information in EPO reimbursement, you can go to CMS links:  

- www.cms.hhs.gov/apps/review/99Spring/99Springpg55.pdf 

- www.cms.hhs.gov/CoverageGenInfo/07_epopolicies.asp.
 
The OIG has its own reports, available at: 
  
- http://oig.hhs.gov/oas/reports/region1/19200506.pdf

- http://oig.hhs.gov/oas/reports/region1/10200516.pdf.

The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.