Oncology & Hematology Coding Alert

Physician offices in 10 western and midwestern states no longer are able to list more than one diagnosis code per procedure on their claim form the result of new requirements that took effect Oct. 1. Listing more than one code will result in claim denial, according to the Health Care Financing Administration (HCFA). The new rule applies to providers in Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming.

Although the edict seems simple one procedure equals one diagnosis code there are a number of oncology-related procedures and drugs that require more than one diagnosis code to prove medical necessity.

For example, Ethyol, an organic thiophosphate cytoprotective agent given to patients with advanced ovarian cancer (183.0) or nonsmall cell lung cancer (162.2-162.9) who are being treated with the chemotherapy drug Cisplatin (J9060, J9062), requires more than one diagnosis code. For most oncology practices, the failure to list both codes will result in claim denial.

Indications and limitations for coverage set forth by Medicare state that Ethyol is indicated only for coverage to reduce the cumulative renal toxicity associated with repeated administration of Cisplatin in patients with advanced ovarian cancer and nonsmall cell lung cancer.

When Two Diagnosis Codes Are Needed

For most providers to get paid for the use and administration of Cisplatin, codes 183.0 or 162.2-162.9 must appear along with the procedure code on the claim form. In addition, a secondary diagnosis code 995.2 (unspecified adverse effect of drug, medicinal and biological substance) must be listed. Because both are integral components to prove medical necessity, providers in the states affected by the Medicare changes have questioned which to use and whether the absence of one will lead to denials or prompt carriers to audit claims.

We have gotten a lot of calls about this, says Barbara Benson, a customer service representative for Noridian Mutual Insurance Co., the Medicare carrier for Arizona and Colorado. People have been asking what to do when there needs to be two diagnosis codes.

Filling Out the Claim

According to HCFA, providers in the 10 states listed above should adhere to the following steps when filling out a claim form:

1. For item 24e, enter the diagnosis code reference number, as shown in item 21, to relate the date of services and the procedures performed to the primary diagnosis.

2. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service, a 1, 2, 3 or 4.

3. For each CPT code, enter the number of that services primary diagnosis code from item 21. In other words, do not enter 1 and 2, or 1 through 4, even if multiple diagnoses [...]