Oncology & Hematology Coding Alert

Inserting the wrong variable in the equation can result in mystifying denial patterns. If your oncology practice is plagued by denials for chemotherapy drugs and administration because the patient doesn't have a cancer diagnosis, you may be able to tweak your coding techniques and recover more if not all you'd like in the way of reimbursement. Some coders believe that when delivering an antineo-plastic drug they should always use the chemotherapy administration codes regardless of the patient's diagnosis. The key to proper reimbursement lies in knowing when to match drug administration codes to diagnosis codes and when to match administration codes to the drug itself. There are two basic ways in which your claims could be going astray, says Jennifer Darling, CORT, PA, billing and collections lead with the Center for Oncology Research and Treatment in Dallas. Your problem may be specific to your intermediary, which could be interpreting medical necessity and/or the primary indications for a drug inappropriately. Or, you could be submitting incorrect administration codes. Chemo Codes Go With Cancer Diagnoses Despite the precautions required and risks associated with chemotherapy drugs, Medicare and many other insurers will not pay for chemotherapy administration unless the diagnosis is cancer (ICD-9 140.0-239.9, V58.1). When employing antineoplastic drugs for non-cancer diagnoses, you are frequently limited to the lower-paying diagnostic or therapeutic infusion codes, says Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett. A Medicare national coverage determination for chemotherapy administration states specifically that the "administration of antineoplastics to patients with a diagnosis other than cancer must be reported with codes 90780-90784, as appropriate."

The therapeutic or diagnostic infusion codes encompass:

90780 Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour

+90781 each additional hour, up to eight (8) hours

90782 Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular

90783 intra-arterial

90784 intravenous. The code range for regular chemotherapy administration includes 96400-96450 (Chemotherapy administration), 96542 (Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents), 96545 (Provision of chemotherapy agent) and 96549 (Unlisted chemotherapy procedure). Chemo Codes Carry Higher RVUs for a Reason No matter why they are administered, all chemotherapy drugs are subject to the same level of coverage. If the physician is using a chemo drug regardless of purpose she must follow particular protocols with antineoplastic agents, such as watching for patient reactions during the infusion. This is why the chemo infusion codes carry higher RVUs (relative value units) than the nonchemo infusion codes, Darling says.

For 2002, one hour of infusion therapy (90780) carries a nonfacility RVU of 1.06, while one hour of chemo infusion therapy (96408) [...]