Oncology & Hematology Coding Alert

Radiation oncology coders should come prepared when they report 79030 or 79035, because their complicated descriptors confuse many coders - which can lead to errors and claim denials.
 
The differences between 79030 (Radiopharmaceutical ablation of gland for thyroid carcinoma) and 79035 (Radiopharmaceutical therapy for metastases of thyroid carcinoma) lie in whether the patient has primary thyroid cancer (193) restricted to the gland itself, or thyroid cancer that has metastasized to another site in the body, says Nan Schellhaas, RT, radiology coordinator at Pendleton Memorial Methodist Hospital in Dallas.
 
Radiation oncologist coders should remember that 79030 represents primary thyroid cancer, whereas you should report 79035 only if the patient's cancer has spread to another body site.
 
You should report 79030 if your oncologist administers the radionuclide dose to ablate a patient's thyroid gland for primary thyroid cancer, Schellhaas says, but you should report 79035 "for administration of the therapeutic dose to a patient whose thyroid cancer has metastasized."

Use 79035 to Represent Metastases

 "The most common sites for metastases of primary thyroid cancer are generally the lungs and thorax areas," says Jacqui Szymanski, RT, a radiology technologist at Associated Imaging Specialists in St. Charles, Ill. Will the insurer become suspicious when it determines that you treated thyroid cancer in a site other than the thyroid, such as the lung, even though your claim carries a thyroid cancer diagnosis? Szymanski says no.
 
Although the cancer originated as malignant thyroid cells that were disseminated throughout the body, the "new" cancer site is secondary lung cancer (196.1, Secondary and unspecified malignant neoplasm of lymph nodes; intrathoracic lymph nodes). Your oncologist should list 197.0 (Secondary malignant neoplasm of respiratory and digestive systems; lung) as the first diagnosis and 193 as the secondary diagnosis to indicate that the primary cancer is thyroid cancer.

Always Report the Dose

In addition to reporting either 79030 or 79035, you should also seek reimbursement for the drug your physician administered, Schellhaas says. "CPT code 79900 (Provision of therapeutic radiopharmaceutical[s]) can be reported in conjunction with both 79030 and 79035 to procure and provide the iodine-131 to the patient. Code 79900, however, is generally replaced with HCPCS code A9603 (Supply of therapeutic radiopharmaceutical, I-131 sodium iodide capsule, per mci) by Medicare carriers." Other insurers may require the HCPCS code, or they may prefer 79900. You should check each individual payer's requirements. Reimbursement for the drugs varies, depending on the amount of the radionuclide needed to either ablate the thyroid gland or treat the metastases, Schellhaas says.

You Can Report E/M Codes

Because radiation oncologists often administer thyroid ablation radiopharmaceuticals in large doses, your physician may hospitalize the patient for 48 to 72 hours or more. If this is the case, you should report a hospital admission (99221-99223, as appropriate for the level of care) in addition to the radiopharmaceutical therapy codes. The National Correct Coding Initiative (NCCI) does not include any edits that bar oncology practices from reporting a hospital admission or subsequent hospital care code (99231-99233) with the therapy, so you can report both the E/M visit and 79030/79035 if you have documentation to show that both are medically necessary and distinct from one another.
 
Your carrier may require you to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if you report it with 79030 or 79035. This modifier tells the payer that the E/M service is separate from the nuclear medicine procedure. Also, remember that the extent of medical record documentation will determine the level of evaluation and management service you should bill.

Review the Operative Note

Suppose your radiation oncologist gives you this procedural note for his or her most recent thyroid cancer procedure:
 
"A 35-year-old patient presents six weeks post-near-total thyroidectomy. Patient ceased taking thyroxine replacement therapy two weeks ago. Admitted patient to the hospital, and patient ingested 300 mci of I-131 to treat thyroid cancer that has metastasized to his lung. Patient was moved to his room for observation and follow-up."
 
Because the cancer spread to the patient's lung, you should report 79035. In addition, you should report 300 units of A9603, because the descriptor refers to one unit "per mci."
 
If the nuclear medicine specialist admits the patient to the hospital, you should also report a code from the 99221-99223 series. Remember to append modifier -25 to
your E/M code to designate the significant, separately identifiable nature of the evaluation service. Your claim therefore might appear as follows: