Oncology & Hematology Coding Alert

... and one that could save your practice

Don't base your oncology diagnosis coding on myths and assumptions -- you are just asking for denials and lost reimbursement. Instead, use our experts' proven strategies so you can report ICD-9 codes with confidence by debunking three common coding myths.

The following oncology coding scenarios will show you how to tighten up your diagnosis coding to guarantee quick reimbursement. Myth #1: Once you precertify, you can't add diagnoses. You precertified a biopsy based on one diagnosis, but after the oncologist started the procedure he discovered other problems requiring surgical attention. Because you precertified only the original diagnosis, you can't report the additional procedures, right? Wrong.

Strategy: You can either precertify a code range or submit the follow-up diagnoses after the fact, says Elisabeth P. Fulton, CPC, a coding and audit specialist in Winston-Salem, N.C.

Example: The oncologist preapproves a bone marrow aspiration (38220, Bone marrow; aspiration only) for a patient with leukemia (204.xx, Lymphoid leukemia). After the oncologist begins the procedure, he aspirates 0.05 ml of liquid bone marrow from the patient's spine. The physician determines the patient actually has myeloid leukemia (205.xx). Entering through another site, the doctor takes a biopsy of the patient's bone marrow (38221, Bone marrow; biopsy, needle or trocar). Because the insurer only preauthorized the procedure based on the lymphoid leukemia diagnosis, should you report both conditions?

Yes, but you can avoid this challenge if you pre-certify a code range rather than just one code, Fulton says. "Before the surgery, tell the insurer's precertification department that the surgeon may perform other procedures if he discovers additional diagnoses," she says. "We tell the insurance company's precertification department that the surgeon may very well perform more than one procedure, depending on what he discovers when he gets in and looks around."

Lesson learned: Insurers rarely ask physicians to pre-certify just one CPT and diagnosis code. Occasionally, however, the payer might ask you to precertify the intended procedure based on the confirmed diagnosis. Therefore, you should precertify 38220 and make clear that your physician may perform and report more procedures if medically necessary.

Caution: If, after the aspiration and biopsy, the insurance company balks at paying for the biopsy, the oncologist should write an appeal letter citing the date his practice requested preapproval, the fact that the practice attempted to precertify a code range, and the fact that he diagnosed myeloid leukemia during the aspiration. Also, make sure you attached modifier -59 (Distinct procedural service) to 38221 to show that the physician performed the procedure separate from the aspiration. Myth #2: You should expect denials if you report signs and symptoms as primary diagnoses. When your oncologist confirms a diagnosis, you have to use that [...]