Oncology & Hematology Coding Alert

Question: I'm confused by Medicare Transmittal 1901. How does it change our current outpatient clinical trial coding?

New York Subscriber

Answer: Essentially, the transmittal clarifies proper ICD-9 coding. CMS provides additional detail that has already been stated in Medicare Claims Processing Manual (MCPM), Chapter 32, Section 69.7, and adds this information to Section 69.6 for healthy trial volunteer claims.

Transmittal 1901 (CR 6776) adds text to Section 69.6, stating that you should report V70.7 (Examination of participant in clinical trial) as the primary diagnosis for healthy control group volunteers. Oncology trials often don't involve healthy volunteers, though, so the rule may not affect most of your trial coding.

For ill trial members, you should still use V70.7 as the secondary diagnosis, listing the disease treated as primary. And remember to designate investigational services using modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study in an approved clinical research study) and routine services using modifier Q1 (Routine clinical service provided in a clinical research study that is in an approved clinical research study approved clinical research study) on the relevant CPT codes.

Resource: You can find the transmittal here: www.cms.hhs.gov/transmittals/downloads/R1901CP.pdf.