Oncology & Hematology Coding Alert

Stop pouring the dollars down the drain. Many of your chemotherapy patients need hydration services, and you should get paid for them.

Documenting separate services is also crucial if the physician is billing for hydration in addition to chemotherapy. For example, when a patient presents for a scheduled chemotherapy treatment and following the chemotherapy becomes dehydrated, the physician treats the patient with a saline-solution infusion.

In this case, you should separately report the chemotherapy, the infusion, and the E/M service. The physician is giving the saline solution as a hydration treatment, not as a vehicle to deliver a different drug, such as one for chemotherapy, says Jeanne Smith, reimbursement specialist for Madrona Medical Group, a large multispecialty group in Bellingham, Wash.

For the chemotherapy treatment, report the appropriate chemotherapy administration code (96400-96549), such as 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour). For the infusion administration for hydration, use the infusion codes (90780-90781).

"Clearly document that the chemotherapy and the hydration therapy were administered sequentially or as separate procedures," Smith says.

For the physician's patient evaluation, which led to the infusion, assign an office visit code (99211-99215). Remember to append the office visit code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The guidelines for chemotherapy administration state, "If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 96400-96549." Your physician's decision to hydrate the patient required a separate E/M service to treat the emergent complication. The final report of the example should read 9921x-25, 96410 and 90780.

The infusion codes include the supplies but not the infused substance. "The supplies, such as needles and tubing, are bundled into the infusion administration codes," Smith says.

Bill the infused drugs separately with the appropriate HCPCS level II J codes. Using the example above, you should report any infused agents, such as J9370 (Vincristine sulfate, 1 mg) for the chemotherapy drug and J7042 (5% dextrose/normal saline [500 ml = 1 unit]) or J7120 (Ringer's lactate infusion, up to 1,000 cc) for the saline solution.

Do not report prolonged services (99354-99357) in addition to the infusion codes (90780-90781) because prolonged services codes are time-based and added to E/M services.

Prolonged services and infusion codes also have different requirements for physician supervision. Under the infusion requirements, the physician must supervise the patient's case but does not have to remain physically present throughout the infusion. Although the infusion codes require the physician's presence in the office, the physician does not have to be in the room where the infusion is administered, Smith says. In contrast, the prolonged services codes require direct (face-to-face) patient contact, so reporting these two code sets together is inappropriate.

If the oncologist decides to report prolonged services instead of the infusion procedure, he or she must have stayed with the patient the entire time. Some private payers do not accept the prolonged services codes, so you should generally use the infusion codes instead.

Sometimes a physician admits a patient to the hospital after in-office infusion. Combine the work performed in the office into the hospital admission code.

You can't bill more than one E/M service per day for the patient, according to CPT coding conventions. "Carriers won't pay for an office evaluation and admission to hospital on the same day," says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. This payment dilemma may arise when, for example, the patient still has persistent vomiting after the chemotherapy, and the physician decides to admit the patient to the hospital.

For the physician's E/M work on that day, assign only a hospital admission code (99221-99223) when admitting from your office, Scott says. Do not report an office visit. Instead, include the history, examination and medical decision-making performed in the office to select a higher-level hospital admit code. In addition, report the infusion and any infused substances. The physician provided these services, and they are billable regardless of whether the hydration succeeds.

Infusion provided in the hospital is not a billable service, Smith says. Payers assume that when the patient receives hydration therapy in a hospital, the hospital staff, not the physician, performs the service. The fees for the administration, the drugs and the supplies are hospital expenses, and the oncologist should not bill for them.

For instance, an oncology physician on day two visits the patient in the hospital and orders infusion for the patient's continued dehydration. You should bill for the physician's E/M services on day two as subsequent hospital care (99231-99233). You should not charge for the in-hospital infusion because the fee is tied to the hospital, not the physician.