Oncology & Hematology Coding Alert

When CPT 2001 included a new code for blood collection from ports, 36540 (collection of blood specimen from a partially or completely implantable venous access device), there was anticipation that it would provide a new billing opportunity and solve the chronic Medicare problem of getting paid separately for port flushes. However, since it was implemented this year, most Medicare and commercial payers will not reimburse for it yet, says Cathy Klein, LPN, CPC, senior consultant with Health Care Economics in Indianapolis, Ind.

Flushing a port may include Heparin to clear the port of clotted blood and may also include drawing blood to keep lines clear. With the absence of payment for this code, the questions are: how should practices use 36540 and what role should it play in coding for blood draws, port maintenance, and port flushes?

Despite the fact that CPT directs oncology practices to use 36540 in a notation under 96530 (refilling and maintenance of implantable pump or reservoir), it may be another year before payers start recognizing it, says Phyllis Klein, president of P.K. Administrative Services, an Englewood, Colo.-based medical billing firm.

It has long been assumed that collecting a blood specimen prior to or after chemotherapy was included as part of the administration and that drawing blood as part of maintaining a port including port flushes was bundled with the E/M service. The emergence of 36540 left the possibility open that payers would unbundle this common procedure from chemotherapy administration and perhaps even prompt Medicare to separate port flushing from 99211 (office or other outpatient visit) and allow 36540 to describe maintenance and flushes.

In the absence of clear direction from payers, Klein still advises practices to use 36540 when billing commercial payers and Medicare for drawing blood from a port. Although reimbursement will not be made, practices will not lose money because most payers bundle this with other services. Additionally, you will be coding accurately for services whether or not you are paid.

But, Klein warns, the code should not be used for anything other than collecting blood from a venous access port. It is designed to obtain a blood specimen to prevent having to do a venipuncture on a patient with poor veins.

So, practices should not use 36540 to report the broader service of port maintenance, including port flushes, says Klein. Coding for port flushes has been the subject of debate, with some payers accepting 96530 while others direct providers to include the service as part of an E/M visit.

As an example of the different ways carriers require practices to bill for port flushes, the following are taken from various local medical review policies (LMRPs):

National Heritage Insurance Company:

They instruct practices to use 99211 for accessing and flushing of a catheter, line or port, only when the service is distinct and separate from chemotherapy administration and other E/M services.

Oncology practices should bill the higher-level visit, 99212-99215, and consider the port flush as part of the office visit.

Blue Cross Blue Shield of Montana:

They consider the accessing of venous access devices for blood collection and/or Heparin flush part of managing the patient and included in the appropriate E/M code.

Supplies, such as needles, syringes and Betadine wipes, are bundled with E/M services and are also not allowed when billed separately.

Associated codes include:

96549 unlisted chemotherapy procedure;

G0001 routine venipuncture for collection of specimen(s);

36415 routine venipuncture or finger/heel/ear stick for collection for specimen(s);

96408 chemotherapy administration, intravenous; push technique;

96530 refilling and maintenance of implantable pump or reservoir;

90784 therapeutic or diagnostic injection; IV; and

J1642 injection, Heparin sodium, 10 units

In addition, these four steps should be followed:

1. Appropriate E/M codes should be billed according to CPT guidelines. E/M service codes should not be upcoded to specifically indicate blood collection or flushing in addition to other services.

2. Code 96549 (unlisted chemotherapy procedure)should not be used to bill separately for accessing a venous port for any reason, including administration of drugs and IV fluids, blood collection or flushing and maintenance of the port. This is part of managing the patient with this type of long-term catheter and is inclusive in the primary service (i.e.,appropriate E/M code).

3. Codes G0001 (routine venipuncture for collection of specimen[s]) and 36415 (venipuncture or finger/heel/ear stick for collection of specimen[s])are not the appropriate codes to bill for routine blood collection via a venous access port. These codes describe routine venipuncture for collection of specimens. Venipuncture is technically different from accessing a port. Also, 96530 (refilling and maintenance of implantable pump or reservoir) is not the correct code for blood collection and/or Heparin flushes.

4. Any additional codes such as, but not limited to 96408 (chemotherapy administration, IV; push technique) and 90784 (therapeutic or diagnostic injection; IV) used to bill performance of a Heparin flush separately from an E/M service is not allowed. Code J1642 may be billed for the cost of Heparin.

Wisconsin Physicians Service Company:

According to this carrier, flushing of a vascular access port prior to administration of chemotherapy (or other medically necessary drug administration) is integral to the administration and is not separately billable. If a special visit is made to a physicians office for the port flushing, 99211 should be used, not 96530.