Oncology & Hematology Coding Alert

Too often, practices searching for codes to describe flushing and maintenance of portable and implantable pumps incorrectly bill for office-based chemotherapy administration (96410, infusion technique, up to one hour; and +96412, infusion technique, one to eight hours, each additional hour [list separately in addition to code for primary procedure]), says Cindy Parman, CPC, CPC-H, co-founder of Coding Strategies, a consulting firm in Dallas, Ga.

The administration codes are not correct in these instances because in most cases the pump is filled and the patient is sent home. He or she is responsible for self- administering the drug, or the pump is programmed to deliver specific doses at certain times, both of which cannot be billed as office-based administration, Parman adds.

The correct codes for a portable and implantable pump are the chemotherapy IV infusion and intra-arterial initiation codes, 96414-96425, and for refilling and maintenance, 96520 (refilling and maintenance of portable pump) and 96530 (... implantable pump or reservoir). These may also include items such as flushing the port and dressing change.

Coding for Initiation of Chemotherapy

The refilling and maintenance of a portable pump can sometimes be connected to the initiation of prolonged chemotherapy administration codes:

IV infusion, push technique 96414 (infusion technique, initiation of prolonged infusion [more than eight hours] requiring the use of a portable pump)

Intra-arterial, push technique 96425 (infusion technique, initiation of prolonged infusion [more than eight hours] requiring the use of a portable or implantable pump) or 96412.

While related, practices should not code the initiation codes (96414, 96425) and the maintenance codes (96520, 96530) on the same day. This will result in a payment denial because Medicare considers these to be a part of the initiation of the therapy. Also, 96414 and 96425 should only be used if the initiation is performed in the office and the patient is later sent home to complete the treatment.

Parman says practices are allowed to code 96414 once per cycle (the number of times the drug is given per treatment). Each time the pump must be refilled, the practice can code 96520 or 96530. For example, if the cycle calls for filling an implantable pump three times, a practice should use 96414 to describe the initiation of the cycle and the first filling of the pump, then they can also bill 96530 for each subsequent refilling during future visits (in this example, two more times). Remember, Medicare will not pay for both chemotherapy administration and refilling and maintenance codes on the same day, Parman adds.

Note: If an implantable or portable pump is used to administer chemotherapy in the office from beginning to end, two other codes should be used: 96410 and 96412.

Correctly Billing Medicare

Pump refilling and maintenance may be covered by Medicare when performed during an office visit, either as part of a face-to-face physician visit or as incident-to services provided by a nurse, nurse practitioner or physician assistant, says Ris Marie Cleland, co-founder of Opline Oncology Services, an oncology coding consulting firm in Lawton, Okla. Medicare guidelines state that payment for pump refilling and maintenance may not be made when this service is provided to hospital inpatients, outpatients, or residents in a skilled-nursing facility. They do, however, allow for the following oncology-related uses of pumps and the refilling and maintenance of them:

Chemotherapy for liver cancer: Intra-arterial infusion of Fluorouracil (J9190) for the treatment of liver cancer (155.0-155.2) and colorectal cancer (153.0-153.9) in which the metastases are limited to the liver and where the disease is unresectable or the patient is not a candidate for surgical excision of the tumor.

Chemotherapy using: Fluorouracil; Cytarabine (J9100- J9110); Doxorubicin (J9000-J9001); Bleomycin (J9040); Vincristine (J9370-J9380), and Vinblastine (J9360), where use is indicated as appropriate.

Opioids for chronic intractable pain: To administer opioid drugs, such as morphine, intrathecally or edipurally for the treatment of severe chronic intractable pain of malignant or nonmalignant origin in patients who have life expectancy of at least three months and who have proven unresponsive to less invasive medical therapy.

There are three main ways to bill a flushing and maintenance of a port when done in the physicians office:

1. Port flush only: The routine accessing and flushing of the implanted port or central catheter is included in the appropriate office visit code. This service is considered part of the regular management of the patients chemotherapy, Cleland says. For these routine visits, an E/M code should be billed instead of the maintenance codes (96520, 96530). The appropriate E/M service in these instances is usually 99211 (office or other outpatient visit), because it is normally performed by a nurse under physician supervision as incident to.

2. Maintenance/Refilling and Flushing: If the visit is more than routine, for example, port flushing, refilling and maintenance are all performed on the same day, practices should bill only codes 96520 or 96530, and not bill an E/M service separately, Parman says. In order to bill an E/M service separate of pump refilling and maintenance, additional E/M services, such as following up on previous chemotherapy treatments, should be performed with port flushes.

3. Maintenance/Refilling, Flushing and E/M visit: In order to bill an E/M service in addition to pump refilling and maintenance, significant and separate E/M services must be documented with the maintenance and port flush, Parman says. A separate diagnosis is not necessarily required, but physician documentation will be essential to establish the medical necessity for and separate nature of the E/M service.