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Part B Insider (Multispecialty) Coding Alert

Drug Reimbursement:

Ease Your Drug Cuts Worries By Focusing On Basics

Published on Fri Oct 01, 2004

Follow the rules and you can hang on to more of your chemotherapy pay

Oncology practices won't know the details of their 2005 payments for drugs and drug administration until the very last minute. But there are steps you can take now to prepare for the worst.

Medicare's shift from Average Wholesale Price to Average Sales Price reduces payment for 32 chemotherapy drugs and administration codes in 2005, which could cost oncology practices a purported $500 million in 2005. Coding experts offer the following tips to shelter yourself from the coming storm:

  • Watch your documentation for Rituximab. Payments for J9310 (Rituximab, 100 mg) will drop by nearly $25 per dose, to $413, according to preliminary figures. But meanwhile, claims for J9310 are under scrutiny and you could stand to lose much more than $25 if you're not careful, warns Lisa Wood, office manager at Cancer Center of the Piedmont in Danville, VA.

    Part B carrier Cigna Healthcare conducted a "probe" review of 100 claims for J9310 from 18 providers in Tennessee, and found that nearly 55 percent lacked the proper documentation, according to Cigna's April 2004 bulletin. Cigna warned that more providers in other states might soon see scrutiny of their J9310 claims as well.

    So it's important to follow these coding and documentation guidelines when you bill for Rituximab:

    1) The patient has finished a "front line" or initial treatment of chemotherapy. Medicare pays for Rituximab when used for relapsed or refractory cancers. Payers may also reimburse one course of Rituximab during initial treatment if the physician administers it in combination with another anti-cancer drug.

    2) The cancer should be CD20 positive, which Medicare requires in the treatment of refractory different types of non-Hodgkin's lymphoma and leukemia.

    3) Documentation records appropriate dosage. Generally, Medicare carriers require oncologists to give Rituximab in 375mg/m2 weekly doses for four weeks.

    4) You must report a covered diagnosis. The best way to ensure that you're listing an appropriate ICD-9 code is to check with your insurer.

    For instance, Medicare carrier HGSAdministrators would accept a physician diagnosis of 202.43 (Leukemic reticuloendotheliosis; intra-abdominal lymph nodes). But, if you submitted 174.x (Breast cancer) as a diagnosis code, HGSA would deny your claim the insurer doesn't accept this code for Rituximab.

  • Remember that you can bill for multiple units of 96408. Starting last January, you can bill one unit of 96408 (Chemotherapy administration, intravenous; push technique) for each drug the physician or staff administered, says Linda Zimmerman, a coding specialist with IMA Inc. in Bloomington, IN. That doesn't mean you can bill for multiple administrations for a single injections, she adds.

    So for example, if the nurse uses the push technique to provide chemotherapy drugs Cisplatin (J9062), Dacarbazine (J9130) and Fluorouracil (J9190), you should report 96408 x 3 in addition to the three drug codes, says Kelly Reibman, CPC, a billing representative for an oncology practice in Easton, PA.

    You should also make sure the medical documentation shows that each drug required additional procedure time, preparation, supplies and patient education, according to the American Society of Clinical Oncology guidelines. This way, you support your case for reporting multiple pushes.

    Some carriers require you to attach a modifier to one or more of the chemo pushes. For instance, if you report 96408 three times in Illinois, Medicare instructs offices to attach modifier -76 (Repeat procedure by same physician) to the second and third charges (96408-76), says Sue Coffee, office administrator at Central Illinois Hematology Onco- logy Center in Springfield, IL.

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