Medicare has made code 96545 (provision of chemotherapy agent) virtually useless because it won't pay for the service separately from chemotherapy administration. But some commercial payers still pay for providing and administering the drug and reimburse for the drug itself. So, oncology practices should continue to consider billing drug provision with commercial payers.
Choosing a Billing Option
Medicare will pay for 96545 separately only if oncology practices use it instead of the J9xxx code for reporting the chemotherapy drug -- for example, if you bill 96545 with 96408 (chemotherapy administration, intravenous; push technique). However, if you want to get paid for each service, you cannot report the drug (for example, doxorubicin, J9000-J9001). How to bill becomes a bit more obvious when you consider that chemotherapy drugs cost hundreds -- if not thousands -- of dollars and 96545 pays less than $100 and isn't even required on the claim form for drug administration. For most practices, reporting 96408 and the appropriate drug code is the preferred option.
For all intents and purposes, Sharon Grimes, CPC, insurance and billing manager for the West Clinic, an oncology practice in Memphis, Tenn., finds 96545 useless. "We don't use the code for Medicare or commercial payers," she says, "because we have no problem getting paid for chemotherapy administration." Even though Grimes doesn't bill the code, she believes it's in a practice's best interest to check its carriers about accepting 96545 along with the chemotherapy administration and drug codes, and whether they will pay all three separately.
Nancy Giacomozzi, office manager specializing in oncology practices with P.K. Administrative Services, a medical billing firm in Lakewood, Colo., thinks differently. "You can still get a handful of (commercial) carriers who are still paying for 96545. That's anywhere from $50 to $75. In my opinion, it's something I'm not ready to give up."
Billing Chemotherapy Components
Medicare describes chemotherapy services in three parts -- physician services, preparation of agent, and chemotherapy administration. Medicare contends that reimbursement for chemotherapy administration includes both drug preparation and drug administration. Potentially, however, you can bill commercial carriers for three components of chemotherapy treatment:
1. Physician service -- includes obtaining history, performing a physical evaluation, prescribing appropriate drugs, educating the patient about the drugs and side effects; reviewing lab tests; and monitoring for drug side effects. Use 99211-99215 (office or other outpatient visit for the evaluation and management of an established patient) to report these services.
2. Preparation of the agent -- includes obtaining the agent, calculating the amount needed and compounding the agent in the medium, maintaining records, and ensuring proper disposal of supplies and refuse. Report 96545.
3. Administration -- includes placing and maintaining temporary venous access, and using and maintaining venous access devices. Basically this is preparing the patient, infusing or injecting the agent, and monitoring the infusion and vital signs.
Example: To report a one-hour infusion of Cisplatin, oncology practices have been instructed to report 96410 (infusion technique, up to one hour), 96545 and J9062 (Cisplatin, 50 mg).
Billing for Medicare Patients
Using a patient with non-Hodgkins lymphoma as an example, a practice should bill Medicare as follows:
1. If a clinician rather than the physician sees a patient who has non-Hodgkins lymphoma (200.0-200.88, 202.0-202.08, 202.8-202.88), report "incident to" services in addition to the chemotherapy administration if the clinician's medical records reflect the physician's active participation in the management of the treatment. The correct code for this service is 99211. If the physician has face-to-face contact, 99212-99215 apply.
2. If the practice administers the chemotherapy rituximab (which is given intravenously) use 99211 for the office visit, J9310 for the drug, and 96410 for IV administration for the first hour as well as the add-on code 96412 for each additional hour.
Coding guidelines and local medical review policies (LMRPs) indicate you can also use 96545 for chemotherapy administration, but you will not be reimbursed for anything beyond that. Medicare will, however, pay for chemotherapy administration without 96545.
Billing Commercial Payers
According to The American Society of Clinical Oncology, some private insurers might use 96545 instead of the J codes for billing chemotherapy drugs, and possibly accept the code for reporting premixed chemotherapy drugs purchased from a supplier. Giacomozzi adds that carriers also might recognize the work involved in obtaining or preparing the chemotherapy agent and understand that fees for administration do not include the cost of providing chemotherapy drugs.
Using the same example of the non-Hodgkins lymphoma patient, in this scenario oncology practices would bill commercial payers as follows:
Report the non-Hodgkins lymphoma codes to describe the disease, and the E/M code to match the level of physician services, and document the medical necessity for the visit. In most cases, the chemotherapy administration visit would not involve physician face-to-face contact; therefore, bill the clinician's or nurse's services as incident to the physician's, which means the most appropriate E/M code would be 99211. If the physician has face-to-face contact, 99212-99215 would be used to report the visit, depending on its complexity. Also report 96545 for the provision and preparation of rituximab along with J9310 for the drug.
