Oncology & Hematology Coding Alert

When it comes to new oncology drugs, providers may have to educate their payers in order to get their fair share of reimbursement.

Oncology practices are constantly filing appeals for new drugs with unlisted J codes and no listing in the compendia, and many denials are the result of insurers' not having up-to-date information, Carolyn M. Davis, CMA, CPC, CCP, CCS-P, CPHT, RMC, with Oncology and Hematology West in Papillion, Neb., told listeners at a recent Coding Institute teleconference. You can gather much of the firepower you need to rebut denials simply by staying current with new drug information.

Where do you turn first? First, gather all the drug information necessary for reimbursement including the average wholesale price (AWP), major diagnostic category number (MDC), FDA indications, supply (name and strength of the drug), and the administration route.

Explore the pharmaceutical company's Web site and gather supportive information. The drug companies can give you the correct unlisted J code, which you can then verify with the carrier, Davis says.

While you're online, contact the reimbursement hotline, which is typically a toll-free call. "A lot of the hotlines are great with helping you to check the insurance and verify the coverage to make sure there's not going to be a problem," Davis says. If you need a certificate for medical necessity, or a letter from the physician explaining why he or she wants to use this new drug, the hotline will let you know.

Pharmaceutical company reimbursement hotlines can also supply you with persuasive information you may not have considered for example, an article that you can attach to a claim written by physicians preferring the drug in question. Most of the major drug reimbursement hotlines will send you comprehensive office practice manager toolkits.

Davis also recommends registering patients with the reimbursement hotline so you and the patient receive the right information to verify coverage. Call Medicare and verify the J code, because it will determine which infusion code you use.

Finally, compile a thorough record of why your claims justify the J code you are claiming.

Include the drug's MDC number, a complete description, the package insert that includes the FDA indication and use, and articles that support the use of the drug. "It takes time for the compendia to be loaded, so you're actually going to help the insurance company become aware of this drug and get it loaded into their computer system quicker than if they were to wait for the update," Davis says.

Paper claims are your best bet. "If you file [a claim] electronically, be aware: It will probably trigger a prepay audit because of the unlisted J code," Davis warns, so the best way to avoid an audit is to put the claim to paper right away.

Because insurance companies are not necessarily going to lead the drug reimbursement charge, Davis says, skip the customer service department and make contact with a nurse, a case manager or a pharmacist in order to teach them what this drug is and how to use it.

Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans, says, "Call the insurance company before starting the patient on therapy, and get approval in writing in advance." Many insurance carriers will give phone approval, but it's in your best interest to ask them to fax you a written approval, Hickey says. "This documentation may not guarantee you will not have problems when it is time to pay but it is very helpful to include in your documentation when seeking payment."

With informed questions and comments, coders can also encourage drug representatives from pharmaceutical companies to learn appropriate reimbursement information. When your drug reps come visiting, they are excited about FDA approval and the success of the drug for the patients, but they often do not adequately address or fully understand reimbursement information you need to process these drugs. So, educate them by asking lots of detailed questions. Eventually, they'll learn to reel off the AWP, MDC, FDA indications, supply and the administration route.

Take a similar tack when dealing with physicians and nurse practitioners. Request that they collect pertinent information for billing. Davis advises asking them to verify the correct diagnosis because without a justifying diagnosis, claims for new drugs will be denied. By including all participants, you will make appropriate reimbursement a concern for all affected members.

If you are confident you have billed out correctly, and a carrier still denies your claim, call Medicare for help from a review analyst. "New drugs can be a very tricky process, a very unusual thing to handle," Davis says. She advises having all your documentation at your fingertips so you can fax it to the analyst at a moment's notice. When all else fails, you can always return to the pharmaceutical company hotlines, some of which offer assistance with denied or under-reimbursed claims.