Pulmonology Coding Alert

Don't ignore chemo codes just because your physician doesn't see cancer patients

You won't get paid for Xolair and intravenous immunoglobulin (IVIG) services unless you have a handle on drug-therapy coding. Follow these expert tips to determine the codes to report for omalizumab, Remicade and other drug administrations.

1. Identify the Drug Substance

The first question you should ask yourself when choosing an administration codes is what type of drug your pulmonologist administered. The drug type leads you to the category of CPT code you'll select from.

If the agent is an anti-neoplastic drug, a monoclonal antibody, or some other sort of biologic response modifier, you can use the chemotherapy administrations codes (96401-96549). If the drug is not in these categories, use the codes for hydration, therapeutic prophylactic, and diagnostic injections and infusions (90760-90779).

Tip: Remember that you can report the chemotherapy administration codes for any physician who gives these types of medications or substances. An oncologist or radiation oncologist doesn't have to be the one providing the service for you to use these codes, says Vicky O'Neil, CPC, CCS-P, owner of The Hazlett Group, a coding and compliance consulting firm in St. Louis.
 
Pulmonologists commonly care for patients with conditions such as cystic fibrosis, asthma, COPD, and pulmonary hypertension. These conditions can require specialized injection and infusion therapies, such as methotrexate, infliximab, and immune globulin, that are now classified within the chemotherapy section of codes.

2. Determine the Administration Approach

Once you've determined the drug substance, the way your pulmonologist administered the drug narrows your code choices even further.
 
When your physician administers a subcutaneous or intramuscular injection, you should use either 96401 (Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic) or 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). If you've identified that your pulmonologist administered a non-hormonal antineoplastic, monoclonal antibody, or biologic response modifier, then you know to choose 96401.

Coding scenario: If your pulmonologist is administering monoclonal antibodies injections for a cancer or non-cancer diagnosis, you should report 96401. For example, your pulmonologist administers omalizumab (Xolair) to a patient with allergic asthma (493.xx). Since Xolair is an IgE blocker or inhibitor that is classified as a monoclonal antibody, 96401 is the appropriate code to report for Xolair injections, O'Neil says.
 
The same concept applies for IV pushes and infusions: If the physician administers a non-hormonal anti-neoplastic, monoclonal antibody, or biologic response modifier, then go to the chemotherapy code section of CPT. Otherwise, use 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) and +90766 (... each additional hour, up to 8 hours).

Within the chemotherapy codes, you'll select the right code by determining the administration approach as follows:

• For an IV push, meaning that the infusion lasts 15 minutes or less, use 96409 (Chemotherapy administration; intravenous, push technique, single or initial substance/drug) and +96411 (... intravenous, push technique, each additional substance/drug).

• Use 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) as the initial code for the first hour of IV chemotherapy administration. 

• If it takes more than one hour for your pulmonologist to administer the drug or if he needs to administer more than one drug, you should also report +96415 (... each additional hour, 1 to 8 hours) or +96417 (... each additional sequential infusion), respectively.

• Report 96416 (... initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump) if the chemotherapy administration lasts longer than eight hours and your physician sends the patient home with a portable or implantable pump, O'Neil says.

Example: Your physician infuses Remicade (inflix-imab) for a patient with sarcoidosis (135). You should report 96413 for the first hour of the infusion and 96415 for each additional hour, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Note: You can also report an IV push when a qualified healthcare professional administers a substance and is continuously present to monitor and observe the patient, Pohlig says.

3. Avoid Separately Reporting Local Anesthesia

Don't fall into the trap of separately reporting "extras," such as IV flushes and IV starts, which CPT considers inherent to the drug administration service code that you report.

The reason: You cannot separately bill for local anesthesia, IV starts, port access, or flushes with the drug administration codes. Also, the fluid your pulmonologist uses to administer the drug is incidental hydration and you cannot separately report a hydration service code, O'Neil says. You can, however, try reporting a HCPCS code to seek reimbursement for the supply of the hydration substance.

Bonus: Review the clip and save chart  to see the old CPT and G codes that correspond to the new 2006 infusion and injection codes.