Oncology & Hematology Coding Alert

Red flag: Reporting 96415 for a 90-minute infusion will land you in hot water

Don't let National Colorectal Cancer Awareness Month go by unnoticed--it's a good time to sharpen your coding skills for the third most common cancer. Get started by taking on these real-world examples.

Size Up Your Skills With This Palliative Scenario

Scenario 1: A patient with metastatic colorectal cancer (primary neoplasm of the rectosigmoid junction, secondary neoplasm of the liver) presents for palliative chemotherapy. The provider administers 350 mg/m2 irinotecan intravenously in 500 mL D5W (5 percent dextrose in water) over 90 minutes.

ICD-9: Report V58.11 (Encounter for antineoplastic chemotherapy) as your primary diagnosis code, says Jean Acevedo, LHRM, CPC, CHC, senior consultant for Acevedo Consulting in Delray Beach, Fla.

Then report the primary neoplasm of rectosigmoid junction with 154.0 (Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectosigmoid junction) and the secondary neoplasm of liver with 197.7 (Secondary malignant neoplasm of respiratory and digestive systems; liver, specified as secondary), Acevedo says.

You can also add V66.7 (Encounter for palliative care) as a fourth code--ICD-9 tells you to code the underlying disease first. Caution: If you omit chemotherapy encounter code V58.11 and report palliative care code V66.7, some payers won't cover the chemotherapeutic drug. Report V58.11 to make it clear that the patient presented for chemotherapy, Acevedo says.

CPT: Ensure proper procedure coding by paying attention to the time recorded for the irinotecan infusion. Because the patient received the chemotherapy infusion for 90 minutes, you should report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). But don't report +96415 (- each additional hour, 1 to 8 hours). You-d need an additional 31 minutes to report this -additional hour- code, according to CPT guidelines.

A 90-minute administration means that you have one hour plus 30 minutes, which falls short of the 96415 requirement by one minute. Helpful: Remind your providers to record exact times for infusions. Rounding down an infusion from 31 minutes to 30 shortchanges your practice.

HCPCS: If you code for the drugs you use, report J9206 (Irinotecan, 20 mg). Remember to factor in the 20 mg included in the descriptor when you choose your units.

Example: The oncologist uses nine 40-mg vials (360 mg)--he administers 350 mg irinotecan and wastes the remaining 10 mg. The 360 mg used divided by the 20 mg in the J9206 descriptor reveals that you should report 18 units of irinotecan. Warning: Payers have varying policies on coding for drug waste. Check with yours to determine their preferences, such as recording wasted drugs on a separate line or appending modifier JW (Discarded drug not administered).

Coding Roundup:

- CPT: 96413 (1 unit)
- ICD-9: V58.11, 154.0, 197.7, V66.7
- HCPCS: J9206 (18 units or per payer preference).

Watch Your Step Around New Infusion Codes

Scenario 2: A patient presents for postoperative chemotherapy for locally advanced rectal adenocarcinoma. He receives 10 mg of the antiemetic prochlorperazine by mouth 30 minutes before chemotherapy, then 20 mg/m2 leucovorin (folinic acid) by IV push, and finally 380 mg/m2 fluorouracil (5FU) by IV push.

ICD-9: As in scenario one, you need to indicate that this was a chemotherapy encounter by reporting V58.11 as your primary diagnosis code. You should also report the neoplasm with 154.1 (Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectum).

CPT: When you choose your -initial- service code from the CPT 2006 hydration and infusion codes, base your decision on the primary reason for the encounter, says Sharlene Evans, CPC, CPC-H, coding supervisor at Seattle Cancer Care Alliance.

In scenario 2, the 5FU chemotherapy is the main reason for the patient encounter, so report the chemotherapy with initial push code 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug), she says.

The leucovorin is an antineoplastic adjunct (used to enhance 5FU), so even though the oncologist administered the leucovorin first, you should report it with a -sequential push- code--+90775 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; each additional sequential intravenous push of a new substance/drug), Evans says.

Tip: If you can't remember whether you-re allowed to use sequential therapeutic infusion/injection codes with primary chemotherapy codes, take a look at your CPT guidelines. Example: A note with 90775 tells you to report it for services secondary or subsequent to specific codes, including 96409.

HCPCS: The provider administered three drugs to this patient. First he received prochlorperazine. Report this with one unit of Q0165 (Prochlorperazine maleate, 10 mg, oral, FDA-approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen).

You also need to report the 20 mg of leucovorin with one unit of J0640 (Injection, leucovorin calcium, per 50 mg). Report the 380 mg of 5FU with one unit of J9190 (Fluorouracil, 500 mg).

Coding roundup:

- CPT: 96409, 90775 (one unit each)
- ICD-9: V58.11, 154.1
- HCPCS: Q0165, J0640, J9190 (one unit each).