Oncology & Hematology Coding Alert

Bone up on documentation tips in the bonus round. Here's a quick chemotherapy infusion coding challenge to keep your skills sharp.
To answer the questions below, refer to this sample infusion encounter for a patient presenting for chemotherapy:

• 8:00-8:20, Aloxi
• 8:20-8:40, dexamethasone sodium phosphate
• 8:40-9:10, Emend
• 9:10-11:45, doxorubicin HCL
• 11:45-1:00, normal saline solution
• 1:00-1:30, Zometa.

1. Which HCPCS Codes Should You Report?
Choosing the proper HCPCS codes for a chemotherapy encounter is an important first step. If you don't know the nature of the drug, such as distinguishing chemotherapy from non-chemotherapy agents, you won't be able to assign the proper administration codes. (See the next two questions for more on administration codes). For this encounter, you should assign the following HCPCS codes.
Aloxi: The appropriate code for Aloxi is J2469 (Injection, palonosetron HCL, 25 mcg). Physicians order Aloxi to help prevent the nausea and vomiting that may occur related to the chemotherapy infusion.
Dexamethasone: Choose J1100 (Injection, dexamethasone sodium phosphate, 1 mg) for the dexamethasone sodium phosphate, which is a glucocorticoid steroid. Note that J1094 (Injection, dexamethasone acetate, 1 mg) would not be appropriate because it specifies acetate rather than sodium phosphate. To simplify accurate coding, "make sure the nursing staff is documenting the correct name of the drug given," says Janae Ballard, CPC, CPC-H, CPMA, CEMC, PCS, FCS, senior consultant at Altegra Health. Then, "verify in the HCPCS book the appropriate code for each drug."
Emend: Emend is also used to prevent chemotherapy-induced nausea and vomiting, which you may see abbreviated as CINV. The appropriate code for this drug is J1453 (Injection, fosaprepitant, 1 mg).
Doxorubicin HCL: In the sample case, the patient presents for chemotherapy. Doxorubicin HCL is the one chemotherapy drug given during the session. You should report J9000 (Injection, doxorubicin hydrochloride, 10 mg).
Saline: Saline infusion is a tricky area in chemotherapy coding. "Hydration infusion is bundled into chemo infusion unless there is medical necessity," such as to prevent toxicities, says Ballard. With the little information available here, there's no indication of documented medical necessity. It's possible the saline was used simply to keep the line open between the morning and afternoon infusions. But in those cases where documentation does support coding saline, you should choose J7040 (Infusion, normal saline solution, sterile [500 ml=1 unit]).
Zometa: Finally, you should report the Zometa using J3487 (Injection, zoledronic acid [Zometa], 1 mg). Zometa is indicated to prevent bone complications, such as osteoporosis in patients on glucocorticoids or to treat bone damage caused by cancer. Physicians also may order Zometa to treat high blood calcium caused by certain cancers.
2. Which Infusion Earns an 'Initial' Code? In the sample case, you should choose an "initial" infusion code for the 9:10-11:45 doxorubicin HCL infusion. The appropriate code, representing the first hour of the infusion, is 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug), says Ballard.
Reason: For physician reporting, you should choose your "initial" infusion code based on the primary reason for the encounter. Additionally, CPT® guidelines instruct you to report only one "initial" service code when administering multiple infusions, "unless protocol requires that two separate IV sites must be used."
Because there's no indication of separate IV sites in this case, you should choose a single "initial" service code. In this case the patient presents for chemotherapy, so you should review the infusions to determine which involve chemotherapy agents. The only chemotherapy infusion is the doxorubicin HCL infusion.
3. What Other Admin Codes Apply?
As explained above, 96413 represents the first hour of the doxorubicin HCL infusion. The infusion lasted from 9:10-11:45, which is two hours and 35 minutes. That means you need to determine how to report the additional one hour and 35 minutes. Hint: Keep in mind that CPT® guidelines restrict the use of +96415 to infusion intervals of greater than 30 minutes beyond 1-hour increments.
You should report one unit of +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]) to represent the second hour. Because the final 35 minutes exceed the requirement for "greater than 30 minutes," you should report a second unit of +96415 for the additional 35 minutes.
Non-chemotherapy: The Aloxi, dexamethasone, Emend, and Zometa are all non-chemotherapy infusions and run for less than an hour each. You should report +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion of a new drug/substance, up to 1 hour [List separately in addition to code for primary procedure]) once for each separate administration for a total of four, says Ballard. Many payers ask that you represent this as one line item of +96367 with 4 units, she says.
Saline: As discussed in the answer to question 1, saline infusion is bundled into chemotherapy infusion unless the provider specifically orders hydration for a documented, medically necessary reason. In those cases where you do have orders and documentation of medical necessity, you should report +96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]).

Bonus Round: How Can You Bulk Up Documentation?

The sample encounter includes only the drugs administered and the start/stop times. But you'll need a lot more information than that to support your coding in the real world.
To complete your HCPCS coding, you'll need to know the precise amounts administered so you can calculate and report units.
The medical record also must include an order from the patient's physician or non-physician practitioner (NPP) for all drugs administered, says Ballard.
For each encounter, "drug administration documentation should include the drug injected/infused, the start and stop times, the total dose given, and the nurse's signature," says Ballard.
But that's not all. Documentation also should state how each drug was administered. For instance, the nurse may record that she accessed a patient's Port-a-Cath, PICC line, or started an IV in a specified vein, Ballard says.