Oncology & Hematology Coding Alert

Understand the different codes for diagnostic and therapeutic services

When your radiation oncologist uses the anti-cancer drug Zevalin (ibritumomab tiuxetan) for radiopharmaceutical treatments, you should choose either 78804 or 79403 based on the type of therapy.

Typically, radiation oncologists use Zevalin along with the drug RituXan (J9310) as a single course of treatment on patients with non-Hodgkin's lymphoma (for example, 202.8x, Other lymphomas) who have not responded to conventional chemotherapy or have relapsed.

Because Medicare hasn't issued national guidelines concerning Zevalin therapy, you should follow your local carrier's specific coding policies. But typically, you should use 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; whole body, requiring two or more days imaging) if the physician localizes a tumor or distributes Zevalin throughout the whole body. The treatment may require more than two days of imaging.

Also, to report the diagnostic dose of Zevalin, you should use A9522 (Supply of radiopharmaceutical diagnostic imaging agent, indium-111 ibritumomab tiuxetan, per mci) for one unit of service.

Tip: Code 78804 usually represents the physician's diagnostic services, oncology coding experts say.

You should also remember that even if the radiation oncologist performs multiple days of radiopharmaceutical testing, you should report 78804 only once.

Here's why: The study requires whole-body gamma camera images within 24 hours after biodistribution of the agents. The physician delivers another dose after a couple of days.

In rare cases, patients may also require a third set of images at 90-120 hours. After providing review and oversight during the entire study, the physician personally supervises a slow infusion of the antibody, watching for potential reactions. The physician should also make sure images are free of motion and artifacts.

After the second or third set of images, the physician will compare the images together, which is why you report only one code, explains Cindy Parman, CPC, CPC-H, RCC, principal and co-founder of Coding Strategies in Powder Springs, Ga. Your documentation should include the complete interpretation and report, along with who did the injections and how long it took.

Many Medicare carriers, such as Group Health NY, state that you shouldn't report the administration of therapeutic radiopharmaceutical separately, because the carrier includes the service in the overall procedure codes. Typically, you can expect a Medicare insurer to pay about $240 for 78804.

When the radiation oncologist delivers Zevalin through monoclonal antibody therapy to the non-Hodgkin's lymphoma patient, you should report 79403 (Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion) and A9523 (Supply of radiopharmaceutical therapeutic imaging agent, yttrium 90 ibritumomab tiuxetan, per mci).

Important: Code 79403 represents the therapeutic portion of the radiopharmaceutical therapy. Nationally, Medicare pays about $300 for the code.

You should assign the code once in addition to the charge for 78804. Code 78804 represents the physician's diagnostic services.

Remember: Code 79400 (Radiopharmaceutical therapy, nonthyroid, nonhematologic by intravenous injection) includes the infusion and supervision services that 79403 represents, so you should not report these codes separately.

If you report 78804 and 79403 together, your Medicare and private carrier will likely require that patients meet a number of criteria to be eligible for the radiation therapy.

For example, HGSAdministrators, Pennsylvania's Medicare payer, requires that the patient has: