Oncology & Hematology Coding Alert

With the host of drugs that accompany chemotherapy, it is often expedient to lump such drugs as Ondansetron, a nausea combatant, in with chemotherapy administration even if the treatments were administered over two distinct time periods.

But dont waste billing opportunities by automatically bundling supportive care drugs with chemotherapy administration, says Laurie Lamar, RRA, CCS, CTR, CCS-P, reimbursement specialist with the American Society of Clinical Oncology in Alexandria, Va.

With proper documentation of chemotherapy and the use of supportive drugs, she says that practices can bill them as two distinct services. When billing for hydration therapy IV (90780 and/or 90781) and chemotherapy IV infusion (96410, 96412, or 96414) performed on the same day, sequentially, or as a separate procedure, you must place modifier -59 (distinct procedural service) on the hydration therapy IV codes.

For example, an oncology practice treating a breast cancer patient who receives an intravenous dose of Ondansetron (J2405), an anti-emetic therapy, just prior to receiving an infusion of chemotherapy (96410, infusion technique, up to one hour) can separate supportive care drugs and chemotherapy administration for billing purposes.

Rules for Medicare call support care drugs to be billed separately if they are administered sequentially to chemotherapy treatment, she says. For coverage of these drugs, payers require that the drug be indicated for use with chemotherapy agents. In the case of anti-nausea medication, the chemotherapy drug must be listed as an agent that causes adverse reactions of moderate-to-severe vomiting.

On the other hand, if the administration of both the anti-emetic drug and chemotherapy is done simultaneously, the practice has no choice but to bundle the administration of the anti-nausea drug with chemotherapy administration, Lamar says.

Note: In addition to using the CPT codes 96400-96549 for chemotherapy administration, oncology practices can also bill 90780 (IV infusion therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour).

Careful Documentation Is Key

Oncology practices need to take care in documenting the sequence of drug administration, says Daniel Johnson, director with Health Care Consultants of America, an Augusta, Ga.-based coding consulting firm with oncology practice clients. [Supportive care] drugs should be coded separately whenever possible, he says.

To prove that the support care drugs and chemotherapy were provided sequentially, Lamar says the record should note the times the drugs were delivered.

For example:
Ondansetron 11 a.m. - 11:45 a.m
Chemotherapy 12:30 p.m. - 1:30 p.m.
Ondansetron 2 p.m. - 2:30 p.m.

But Lamar cautions coders to be on guard against vague notations in the documentation, such as: Ondansetron, Chemotherapy from 11 a.m. to 2:30 p.m.

This scenario would be coded:

Simultaneous Sequential
Administration Administration
96410 96410
J9060 90780-59
J2405 90781
J9060
J2405

Some insurance carriers may require modifier -59 on the 90781, some may not. Check with your carriers for specific information.

Note: Billing for emetogenic therapy with these agents must also include the chemotherapy ICD-9 code (V58.1), and the appropriate ICD-9 code for the cancer being treated (140-208.9). Code V58.1 and the ICD-9 code for the treated cancer also serve as the documentation required to establish the medical necessity of the treatment and should be submitted with each claim.

Consolidate Time

Lamar also advises practices to consolidate the time that supportive care drugs are given in conjunction with a chemotherapy treatment. Rather than treating the administration of support care drugs administered before and after chemotherapy treatment separately as two distinct services, the cumulative time of both should be billed as one. Using the example above, the 11 a.m. - 11:45 a.m. time for Ondansetron would be billed with the 2 p.m. - 2:30 p.m. dose of the same drug. If the cumulative time is greater than one hour, the claim should include both 90780 and 90781 (each additional hour, up to eight hours(.

Billing for Intravenous Infusion

Like anti-emetogenic drugs, hydration therapy intravenous (IV) infusion (90780 and/or 90781) should be bundled into the payment for chemotherapy IV infusion (96410, 96412, or 96414) when administered simultaneously, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C. Separate payment for hydration therapy and chemotherapy, IV infusion is allowed when these services are administered sequentially or as separate procedures.

Separate payment for saline or other intravenous solution used for hydration, with or without chemotherapy is allowed. However, any saline or intravenous solution used for the administration of a chemotherapy drug is considered by Medicare to be included in the reimbursement for the chemotherapy IV infusion. For example, if a patient is given hydration with a 0.9 percent sodium chloride solution prior to the administration of Cisplatin (J9060), the saline used to hydrate the patient prior to administration of the chemotherapy drug can be submitted to Medicare for reimbursement. However, if the same patient is given a 50-ml bag of intravenous solution that is used to mix the drug, the solution is considered to be included in the reimbursement for the chemotherapy IV infusion.

Beware of Orally Administered Support Care Drugs

Callaway-Stradley also warns billing staff to be wary when billing for orally-administered support care drugs, such as oral anti-emetics (Q0163-Q0181). These can be tricky to code because they are self-administered drugs. Generally, Medicare does not pay for self-administered drugs. However, it does allow exceptions for oral anti-emetics that are full therapeutic replacements to intravenous anti-emetics.

While these drugs can be billed separately from chemotherapy administration if the physician dispenses the pills in the office and later sends the patient home with the medication, the physician cannot bill for their administration because code 90780 is for intravenous therapy use only. (See related article, Correctly Code for Oral Chemotherapy on this page.)

Note: Callaway-Stradley also says that 90780 is not applicable to therapy provided in a hospital setting. Code 90780 in that setting is considered a facility-specific code; the hospital is the organization that rightfully should be billing for the service.