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Oncology & Hematology Coding Alert

Tired of Payers Denying Your Faslodex Claims? Try Injection Code 90782

Published on Fri Jun 25, 2004

Why assigning chemo codes 96400-96459 isn't always your best bet

You can strengthen your Faslodex (fulvestrant) administration claims if you use up-to-date drug codes, document the metastatic cancer, report a therapeutic injection, and code per monthly dose.

Learn New J Code to End Unclassified Confusion

In January 2004, CMS ended nearly two years of confusion and debate among oncology coders when it introduced J9395 (Injection, fulvestrant, 25 mg) as the new code for Faslodex.

Before J9395, oncology coders argued about whether to assign J9999 (NOC [Not otherwise classified] antineoplastic drug) or J3490 (Unclassified drugs) for Faslodex. But many practices used J3490 because drug companies required the code and because the drug is an estrogen receptor antagonist, says Lisa C. Wood, office manager at Cancer Center of the Piedmont in Danville, Va. On the other hand, some insurers paid only for J9999.

Now, however, you should assign J9395 when the oncologist or nurse provides Faslodex to postmenopausal women who have metastatic breast cancer that has not responded to anti-estrogen therapy, Wood says.

You'll Need to Use Primary and Secondary ICD-9 Codes

Drugmakers intended Faslodex to treat postmenopausal women with certain kinds of breast cancer. But your oncologist may also use the drug to treat male breast cancer patients.

For instance, private and Medicare carriers, such as First Coast Service Options of Florida, cover both male and female breast cancer patients. So, your oncologist can use the following ICD-9 codes as the primary diagnosis, when appropriate:

  • 174.0-174.9 -- Malignant neoplasm of female breast
  • 175.0-175.9 -- Malignant neoplasm of male breast.

    Because some therapies, such as Faslodex, require a metastatic breast cancer diagnosis to qualify for coverage under most payer plans, the documentation should list a secondary diagnosis code, says Cheryl Bilton, CPC, billing manager, Regional Hematology Oncology Associates in Langhorne, Pa. This secondary code represents the site where the cancer has spread. Your ICD-9 coding options may include:

  • 196.0-196.9 -- Secondary and unspecified malignant neoplasm of lymph nodes
  • 197.0-197.8 -- Secondary malignant neoplasm of respiratory and digestive systems
  • 198.0-198.8 -- Secondary malignant neoplasm of other specified sites.

    Keep Your Chemo, Therapeutic Codes Straight

    Many breast cancers have estrogen receptors that stimulate tumor growth. The physician or nurse injects Faslodex into the patient to reduce estrogen receptors. Therefore, drugmakers classify Faslodex as a hormonal drug.

    This means you should assign therapeutic injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular), Wood says.

    Problem: Many oncology coders mistakenly believe that if a drug has a chemotherapy-related J code (J9000-J9999), they must assign a chemotherapy administration code (96400-96549) when reporting the therapy.

    Solution: Remember to list a chemotherapy administration code only when the physician or nurse uses a drug that targets the cancer cell (antineoplastic), not a hormone inhibitor that interferes with tumor growth. Faslodex administration, for instance, provides the downward regulation of the estrogen receptor proteins in human breast cancer cells but is not an antineoplastic drug, according to oncology coding experts.

    That's why you should assign 90782 for Faslodex administration, unless your carrier requires a different code. Also, remember that when you report the administration, you should attach one of the above breast cancer or secondary malignant neoplasm codes to 90782.

    Don't Overlook Faslodex's Billing Schedule

    Medicare and private payers require you to report 90782 and J9395 for Faslodex administration per monthly dose. That means you have to follow the specific dose guidelines to total a month's use. You should not, however, bill the drug every month, regardless of the amount the physician used.

    Reason: Faslodex's monthly dose equals 250 mg. And because J9395 represents only 25 mg of the drug, you have to bill 10 units to report a month's dose.

    For example, Faslodex is available with two administration options, Bilton says:

  • a single prefilled 5-ml IM injection that equals 1 x 250 mg
  • two prefilled 2.5-ml IM injections that equal 2 x 125 mg for a total of 250 mg.

    How it works: If the nurse opens a single package with two 2.5-ml syringes, he must administer both syringes to qualify for the 250-mg recommended monthly dose. Therefore, you must bill Faslodex per 25 mg, so you would report J9395 x 10, which equals 250 mg, or a month's dose.

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