Oncology & Hematology Coding Alert

Oncologists are equipping more of their patients with ambulatory infusion pumps that administer chemotherapy outside of the office. The supplies associated with these pumps are usually reimbursable, but billing for the pumps themselves must be done carefully. You have to take into account where and when the pumps are used and whether the oncology practice owns or rents them.
 
Depending on several factors, practices should use either chemotherapy administration codes 96410-96423 (the series that describes infusion pumps) or E codes, but never both, says Riise Cleland, CPC, president of Oplinc Oncology Services, a coding consulting firm in Lawton, Okla.

 
Oncology practices commonly fill patients' pumps, provide instructions on their use,  send patients home to self-administer the first dose of chemotherapy, refill subsequent doses, then disconnect the pump when therapy is completed.
 
In these cases, Medicare considers administration of the chemotherapy agent self-administered, so you must bill the appropriate E code and the cost of the drug to your durable medical equipment regional carrier (DMERC). Oncology practices that own or rent ambulatory pumps for patient home use should report the following E codes:

 

E0779 -- ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater
 

E0780 -- ambulatory infusion pump, mechanical, reusable, for infusion less than eight hours
 

E0781 -- ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient
 

E0782 -- infusion pump, implantable, non-programmable
 

E0783 -- infusion pump system, implantable, programmable (includes all components, e.g., pump, catheter, connectors, etc.)
 

E0785 -- implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement
 

E0791 -- parenteral infusion pump, stationary, single or multichannel.

 
If your oncology practice does not own or rent its pumps, you cannot bill the DMERC because there are no costs to recoup. The practice initiates pump use and refills and maintains the pump. Therefore, you can report only 96414 (infusion technique, initiation of prolonged infusion [more than 8 hours], requiring the use of a portable or implantable pump) and 96520 (refilling and maintenance of portable pump) to Medicare for reimbursement.
 
Patients who use infusion pumps at home might need help in starting treatment. When the patient comes to the office to have the pump initiated, report 96414. If the patient requires return visits to refill the pump, the correct code is 96520. 
 
But if a practice sends a patient home with a pump without initiating it, the drug was not administered in the office so you cannot report the administration codes.  
 
Medicare's reimbursement includes the expense of acquiring and maintaining the pump. Payment for 96410-96423 encompasses these costs and those associated with nursing services and chemotherapy administration.

 
In addition to initiating the treatment, an oncology practice may bill for an E/M visit, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H. If the patient's oncologist was not present during this visit, use 99211 (office or other outpatient visit for the evaluation and management of an established patient), Towle says.
 
To bill for a higher level of service (99212-99215), a physician must be present, and three components -- history, examination and medical decision-making -- must be completed and documented to support the chosen E/M level. Cleland says oncology practices must also follow medical-necessity guidelines.
 
To bill an infusion pump, practices must follow special coverage instructions for both external and implanted pumps. Medicare and DMERCs cover the following oncology-related uses of external infusion pumps:
 

Chemotherapy for liver cancer is covered for the treatment of primary hepatocellular carcinoma or colorectal cancer when the disease is unresectable or when the patient refuses excision of the tumor.
 

Morphine infusion for intractable cancer pain is covered for the treatment of intractable pain caused by cancer, in either an inpatient or outpatient setting, including hospice.
 
 
Other uses are covered if the provider's medical staff verifies the appropriateness of the therapy and the use of the prescribed pump for the individual patient.
 
Medicare covers the following oncology-related uses of implanted infusion pumps:
 

Chemotherapy for liver cancer is covered for intra-arterial infusion of 5-FU (J9190) for the treatment of liver cancer on patients with primary hepatocellular carcinoma or Duke's Class D colorectal cancer in which the metastases are limited to the liver and when the disease is unresectable or the patient refuses surgical excision of the tumor.
 

Opioids for chronic, intractable pain are covered when used 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 a life expectancy of at least three months and who have proven unresponsive to less invasive medical therapy.
 
Note: As proof that less invasive medical therapy was not effective, Medicare wants documentation that the patient did not adequately respond to noninvasive methods of pain control, such as systemic opioids. This should be indicated in the patient record by referencing patient history, Towle says. Medicare also requires a preliminary trial of intraspinal opioid drugs administered through a temporary intrathecal or epidural catheter to administer acceptable pain relief and an acceptable degree of side effects and patient acceptance.

 
Unlike in-home use of infusion pumps, in-office pump use, whether external or implanted, is not billed separately from chemotherapy administration. The appropriate billing codes for use of infusion pumps during in-office chemotherapy are 96410-96423. If an external infusion pump is used, oncology practices may also bill their DMERC for the cassette used to hold the drug in the pump. Code A4222 (supplies for external drug infusion pump, per cassette or bag [list drug separately]) should be reported.
 
However, some practices incorrectly use E codes to bill for pump rental: They report E0779-E0781 for in-office infusion-pump use to account for the cost of maintaining it. You cannot bill E codes in these cases because Medicare considers their use as part of in-office chemotherapy administration, Cleland says.