Oncology & Hematology Coding Alert

Answer: The keys are concurrent administration of the chemotherapy and therapeutic drugs versus sequential administration of both, and good notes.

For Medicare patients, Medicare Part B routinely will not pay separately for concurrent administration of antiemetics with 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 (each additional hour) with the administration of chemotherapy drugs, 96410 (infusion technique, up to one hour) and +96412 (infusion technique, each additional hour).

For the physician to get paid using modifier -59 (distinct procedural service) with 90780 and +90781, the billing must include medical notes showing clearly that the physician furnished the antiemetics before or after the actual administration of chemotherapy drugs. The notes should plainly state the start and stop times of the administration of the antiemetics and the start and stop times of the administration of chemotherapy drugs, and prove the administration of the drugs occurred sequentially, not concurrently.

Aside from antiemetics, Medicare routinely does not cover the infusion of saline or other non-chemotherapy drugs using 90780 and 90781, when the drugs are administered concurrently with chemotherapy infusion. However, the physician should bill for the actual drugs and biologicals using the appropriate HCPCS J-codes describing the actual drugs. Saline is not reimbursable.

Section 4557 of the Balanced Budget Act (BBA) of 1997 provides coverage for oral antiemetic drugs as full therapeutic replacements for intravenous dosage forms as part of a chemotherapeutic regimen, provided that the drug is administered or prescribed by a physician for use immediately before, at or within 48 hours after the time of administration of the chemotherapeutic agent.

If the physicians office bills for all three to non-Medicare payers and those payers deny the 90780 the oncologist should challenge the denial, demand that the payer provide their medical policy and determine if the third-party payer uses Medicare Part B medical policies. If the third-party payer cannot provide such policy the physicians office should appeal to their state insurance commissioner and ask for help getting clarification or payment.

Editors note: Mike Lewis, healthcare consultant with Mathieson Moyski Seler & Co., an accounting firm that offers reimbursement consulting to multi-specialty practices that include oncology provided an answer to this You Be the Coder question.