Oncology & Hematology Coding Alert

Question: We recently started billing for a hematology/oncology group and received our first rejection for an unlisted-procedure code. The code they used was 96549 (Unlisted chemotherapy procedure) to indicate accessing a Port-a-Cath. I am new to oncology coding, so I have two questions: Is this is a billable service and, if it is, what code should we use?

Illinois Subscriber

Answer: A Port-a-Cath is a device that is implanted under the skin and is used to deliver chemotherapy directly to the bloodstream, or to retrieve blood from the bloodstream. Routine accessing and flushing of the Port-a-Cath is not a billable service, but the supplies used for the service are billable.

The only exception to the "routine access" rule is if the patient comes to the office for port flushing and no other service, then according to the Medicare Fee Schedule you should charge 99211 (Office or other outpatient visit ...) with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). The Medicare Fee Schedule for Physicians Services, section 15400, specifically states that "flushing of a vascular access port prior to administration of chemotherapy is integral to the chemotherapy administration and is not separately billable. If a special visit is made to a physician's office just for the port flushing, code 99211 (Brief office visit) should be used."

If, however, you are accessing a port to draw blood for lab tests, you may bill code 36540 (Collection of blood specimen from a partially or completely implantable venous access device).

In general, billing details on an unspecified code are hard to find. An unspecified code would naturally not carry an RVU because you can't have a set reimbursement rate on a code whose value could change with each billing. 96549 has a status code of C (Carriers price the code), meaning that each carrier and claims adjuster will determine how they will handle and process the claim. In the real world, it sometimes happens that the same claims adjuster may pay the code on one claim and deny it on another.