Oncology & Hematology Coding Alert

Medicare takes up some slack with administration codes

Although Medicare has reduced payment for 2004 drug codes, you may be able to recoup some of the lost revenue when you report drug administration codes. (See "2004 Medicare Drug Rates Decrease J Code Reimbursement" on page 19.) The 2004 Medicare Physician Fee Schedule introduced a 100-500 percent payment increase for codes 96400-96542.
 
Reimbursement increased because CMS added 0.17 RVUs to the administration codes, which equals the RVUs for E/M code 99211 (Office or other outpatient visit for the E/M of an established patient ...). Generally, coders use 99211 for "nurse-only visits."
 
Therefore, Medicare no longer allows you to report 99211 for the same patient and on the same day as 96400-96542 and 90780-90788. (See "Watch Out: You Can't Report 99211 and 96408 to Medicare" .)

Expect Improved 96520 Reimbursement

Of all the chemotherapy administration codes (96400-96542), 96520's (Refilling and maintenance of portable pump) increase of 494 percent was the largest. You should report this code when the physician or nurse refills a patient's chemotherapy pump.
 
For example, the oncologist sends a colon-cancer patient home with a portable pump. When the pump becomes empty, the patient returns for a refill, and you report 96520, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent oncology coding consultant based in New Orleans.
 
In 2003, 96520 paid $34.58 and carried 0.94 RVUs. Now, however, you can expect the code to pay $205 and carry 4.17 RVUs.
 
But to bill for 96520, make sure the physician initiated the chemotherapy infusion in the office, and the patient didn't begin treatment at home. Medicare will pay only for physician-initiated pump infusions.
 
To get paid for the oncologist's chemotherapy pump's initiation in the office, use 96414 (Chemotherapy administration, intravenous; infusion technique, initiation of prolonged infusion [more than 8 hours], requiring the use of a portable or implantable pump), Hickey says.
 
This year, CMS reimburses 96414 at an average of $269, compared to $51 last year, a difference of more than $200.

Get More Reimbursement With Chemo Infusion

You should also expect significant payment increases for infusion codes 96422 (Chemotherapy administration, intra-arterial; infusion technique, up to one hour) and +96423 (Chemotherapy administration, intra-arterial; infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]).

If you report 96422, you'll receive about $268, an increase of $200 from 2003 rates. If you also used 96423 last year, you probably received about $18.39, a rate based on 50 RVUs. In 2004, however, if you assign 96423, you'll get paid about $105.96, a jump of 476 percent, the second largest among the chemotherapy codes.
 
Tip: The big increases won't mean a thing if you don't know how and when to use the codes. Remember that you can never attach modifier -59 (Distinct procedural service) to 96423 because it's an add-on code. Also, you must use 96423 in conjunction with 96422, which had the third largest percent change at 465.
 
Suppose your oncologist administers intra-arterial chemotherapy using infusion technique on a patient with liver cancer (155.0, Malignant neoplasm of liver and intrahepatic bile ducts; liver, primary). For the first hour, you should report 96422, and you'll receive $268. But if the infusion lasts another hour, for instance, you'd also use 96423 and pick up an extra $105.
 
Note: The above drug-payment rates were based on national averages supplied by the American Society of Clinical Oncology in Alexandria, Va. The rates include a wage index of 1 percent. Because payment rates vary by locality, you should check with your local carrier for specific pricing information.