Oncology & Hematology Coding Alert

Oncology practices that have been billing for both chemotherapy administration and the use of infusions pumps and have had difficulty getting reimbursed for the latter may be running into trouble for a good reason they may be wrong when they bill and expect to be reimbursed for both.

Using infusion pumps in the office, whether external pumps or internal pumps, is not a billable item, says Elaine Towle, practice administrator for New Hampshire Oncology and Hematology, an oncology practice in Hooksett. The proper way to bill for using infusion pumps during in-office chemotherapy is to use codes 96410-96423 (chemotherapy administration, infusion technique). On the other hand, if a practice sends a patient home with a pump, it cannot use the chemotherapy infusion codes (96410-96423) because there was no office administration of chemotherapy drugs. Instead, Medicare considers the administration of the chemotherapy agent to be self-administered and the provider is entitled to bill only for the cost of the drug itself.

You cant get there from here, Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., in Dallas, Ga, says of billing both chemotherapy administration and the use of infusion pumps.

Billing Opportunities

A common procedure in these situations is for the oncology practice to fill the pump, teach the patient how to use the pump, send the patient home to self-administer the first dose of chemotherapy, refill subsequent doses, and then discontinue its use when the therapy is completed. Despite not being able to bill 96410 through 96423, this procedure does allow for several billing opportunities.

First, Towle says, there are chemotherapy administration codes that apply in these instances. Filling and refilling the pump should be coded separately, using code 96414 (infusion technique, initiation of prolonged infusion [more than eight hours], requiring the use of a portable or implantable pump), 96520 (refilling and maintenance of portable pump) or 96530 (refilling and maintenance of implantable pump or reservoir).

The next billing opportunity is the E/M service associated with the office visit the patient made to receive the pump and learn how to use it. Of course, the requirements of an E/M visit must be met. If the patients physician was not present during this visit, use 99211, the lowest level visit for an established patient, says Towle, because code 99211 does not require a physicians presence. Before correctly billing for a higher level of service, 99212-99215, a physician must be present and the three components history, examination, and medical decision-making must be completed and documented.

Another billing opportunity is the rental of the infusion pump. Some practices may be using E codes incorrectly to bill for rental of the pumps with evaluation and management (E/M) service code 99211 (established patient, office or other outpatient visit). They may make the error of billing the E codes to their Medicare carrier. Instead, they should be billing these codes to their durable medical equipment regional carrier (DMERC), which requires the practice to hold a provider number, Parman says. (Application forms for a provider number can be obtained either on-line [check the National Supplier Clearinghouse Web site] or by calling National Supplier Clearinghouse at 803-754-3951.) In addition to having a provider number, the practice also must own the pumps it is billing for. If a practice rents the pumps from a supplier, it is the suppliers responsibility to bill DMERC for the pump rental.

Infusion Pump Codes

The E Codes cover durable medical equipment but cannot be billed for infusion supplies because Medicare considers their use as part of in-office chemotherapy administration.

Infusion pump billing may include the following E codes:

E0779, ambulatory infusion pump, mechanical
reusable, for infusion 8 hours or greater;
E0780, ambulatory infusion pump, mechanical,
reusable, for infusion less than eight hours;
E0781, ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient;
E0782, infusion pump, implantable, non-programmable;
E0783, infusion pump system, implantable,
programmable (includes all components, e.g., pump
catheter, connectors, etc.)
E0785, implantable intraspinal epidural/intrathecal) catheter used with implantable infusion pump, replacement;
E0791, parenteral infusion pump, stationary, single or multichannel.

Medicare-approved External Infusion-pump Uses

In addition to requiring a provider number and knowing which E codes to bill, there are special coverage instructions that practices must follow before they can bill DMERC for use of an infusion pump. Medicare covers the following oncology-related uses of external infusion pumps:

Chemotherapy for liver cancer. The external chemotherapy infusion pump is covered when used in the treatment of primary hepatocellular carcinoma or colorectal cancer where the disease is unresectable or when the patient refuses excision of the tumor.

Morphine for intractable cancer pain. Morphine infusion by external infusion pump is covered when used in the treatment of intractable pain caused by cancer and used in either an inpatient or outpatient setting, including hospice.

Other uses. External infusion pumps are covered if the contractors medical staff verifies the appropriateness of the therapy and use of the prescribed pump for the individual patient.

Medicare-approved Implantable Infusion-pump Uses

Medicare covers the following oncology-related uses of implantable infusion pumps:

Chemotherapy for liver cancer. The implantable pump is covered for intra-arterial infusion of 5-FUdR for the treatment of liver cancer on patients with primary hepatocellular carcinoma or Dukes Class D colorectal cancer in which the metastases are limited to the liver and where the disease is unresectable or the patient refuses surgical excision of the tumor.

Opioids for chronic intractable pain. An implantable pump is covered when used to administer opioid drugs, such as morphine, intrathecally or edipurally for the treatment of severe chronic intractable pain of malignant or non-malignant origin in patients who have life expectancy of at least three months and who have proven unresponsive to less invasive medical therapy.

Medicare uses less invasive medical therapy to mean the patients history indicates that he or she would not respond adequately to non-invasive methods of pain control, such as systemic opioids. Medicare also requires that a preliminary trial of intraspinal opioid drug administration must be done with a temporary intrathecal or epidural catheter to administer acceptable pain relief and an acceptable degree of side effects and patient acceptance.

Parman adds that if an implantable infusion pump is used for intra-arterial infusion of a chemotherapy drug, physicians also might bill code 36260 (insertion of implantable intra-arterial infusion pump [e.g., for chemotherapy of the liver]), 36261 (revision of implanted intra-arterial infusion pump) or 36262 (removal of implanted intra-arterial infusion pump).