Oncology & Hematology Coding Alert

Revealed: Why using modifier -59 can mean the difference between payment and denial

With your chemotherapy drug reimbursement taking a hit in 2005, you don't want simple coding mistakes to lead to even more lost revenue for chemotherapy administration. To get what you deserve, you should know how to report same-day pushes and infusions, and therapeutic infusion and injections. 1. Use J Codes, Modifiers to Support Multiple 96408 Charges Suppose the oncologist or nurse provides multiple "push" chemotherapy treatments to the same Medicare patient on the same day. As of Jan. 1, 2004, you can report 96408 (Chemotherapy administration, intravenous; push technique) for each drug the physician or staff administered, says Linda Zimmerman, a coding specialist with IMA Inc., a Bloomington, Ind.-based multi-specialty practice that includes oncologists.

"This does not mean multiple chemotherapy administrations are payable for a single chemotherapy injection," Zimmerman says. "What this means is that you can report more than one administration on a day if multiple drugs are administered."

For example, 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.

Another way: Some Medicare carriers require that you 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 Oncology Center in Springfield, Ill.

When billing Indiana Medicare, you should attach modifier -59 (Distinct procedural service) to the second and third "push" administration encounters, Zimmerman says. On the other hand, in Pennsylvania, the local Medicare carrier doesn't require any modifiers, Reibman says.

The bottom line: You should only report 96408 multiple times when the oncologist or nurse administers multiple drugs. But check with your local carrier before you attach any modifiers. 2. Know Which Infusion Codes Are Bundled Reporting multiple chemotherapy infusions (96410-96414) can be trickier than multiple push administrations because the National Correct Coding Initiative (NCCI) edits consider the infusion codes mutually exclusive.

"For a given anti-cancer agent, only one intravenous route (push or infusion) is appropriate at a given chemotherapy session," Zimmerman says. "But Medicare and commercial payers recognize that frequently combination chemotherapy is provided by different routes at the same session."

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