Oncology & Hematology Coding Alert

The arsenal of anticancer drugs grows larger with every promising clinical trial. Unfortunately, codes for new drugs are not established as quickly, leaving practices unsure of the appropriate code. It isnt always as simple as using J9999 (not otherwise classified, antineoplastic drug). Oncology practices should know the rules behind this code to avoid denials even when local medical review policies (LMRPs) say the code should be used with the new drug.

Most recently, chemotherapy drugs Herceptin (J9355), Doxil (J9001) and Epirubicin (J9180) were among those drugs that had to be coded using J9999. While they were assigned the above permanent codes in 2000, they serve as examples of how oncology practices should approach billing for commonly used unclassified drugs.

There will certainly be more new chemotherapy drugs that will have to be coded with J9999, says Nancy Giacomozzi, office manager for P.K. Administrative Services, a medical billing agency based in Lakewood, Colo., which serves several oncology practices. The following steps will guide you through the process of how to use HCPCS J9999 and ensure reimbursement:

1. Coverage: Make sure payers cover the drug. Often private insurers, especially managed-care organizations, require prior authorization before a drug is used. Medicare carriers publish their LMRPs, which indicate whether a new drug is covered and if J9999 should be used.

2. Communication: Increasing reimbursement using codes for unassigned items requires communication between the provider and payer prior to the performance of any new procedure or use of new drugs or medical supplies.

3. Written explanation: Send the insurer a letter explaining that the physicians office will be using a drug that is now without a CPT or HCPCS code. Along with the letter, the provider should send current literature describing the efficacy of the drug in similar situations.

4. Documentation: The code, however, must be supported by proper documentation, says Cathy Klein, LPN, CPC, senior consultant with Health Care Economics in Indianapolis. Although documentation is a standard requirement in all coding matters, it is especially important when coding for an unclassified drug. Medicare wants to guard against blanket use of J9999 to garner payment for drugs that are not covered or medically appropriate.

Herceptin, for example, requires the following:

documentation in the medical record must contain a history and physical pertinent to the indications of this policy;

documentation must support the medical necessity and frequency for administration of this agent; and

when a portion of the drug is discarded, the medical record must clearly document the amount administered and wasted.

5. Medical necessity: When billing for an unclassified code, the ICD-9 code that precisely describes the disease must match those a Medicare carrier indicates is a covered diagnosis for a specific chemotherapy drug.

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