Oncology & Hematology Coding Alert

See how your day 1 coding differs from day 15.

The Stanford V regimen involves seven basic drugs, but the patient won't be receiving all of those drugs each treatment day. To keep your coding straight, take advantage of this outline of what to expect.

Remember: The codes you report should reflect the services and drugs provided and documented. Don't assume every case will merit the same HCPCS codes.

Background: The goal in developing the Stanford V regimen for Hodgkin's lymphoma (201.xx, Hodgkin's disease) was to provide a chemotherapy regimen that achieved high remission rates with fewer side effects than ABVD, such as pulmonary damage and sterility (see Oncology and Hematology Coding Alert, vol. 12, no. 3, for more on ABVD). The Stanford V treatment cycle is 28 days long, and patients typically undergo three cycles.

The patient may have radiation therapy, as well, depending on the stage of the disease.

Day 1: Watch for Mechlorethamine, Doxorubicin, and Vinblastine On the first day of the treatment cycle, the patient typically receives three of the drugs in the regimen, as noted below.

Mechlorethamine: Also known as Mustargen, mechlorethamine is an antineoplastic nitrogen mustard which is highly toxic in both powder and solution forms and should be handled with extreme care. The appropriate HCPCS code for this mustard derivative is J9230 (Injection, mechlorethamine hydrochloride, [nitrogen mustard], 10 mg), says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey and MAC J-12 chair for COA Administrators' Network.

Note: Some sources indicate other mustard derivatives may be used instead, such as cyclophosphamide or ifosfamide. As always, you should base your coding on the drugs the oncologist ordered and the route and duration of the administration as documented.

Doxorubicin: Also administered to the patient on day 1 is doxorubicin, an anti-tumor antibiotic. The brand name you'll likely see for this is Adriamycin, Matola notes, adding that the proper code is J9000 (Injection, doxorubicin hydrochloride, 10 mg).

Vinblastine: Staff also administers alkaloid cell toxin vinblastine on day 1. For this agent, also called Velban, you should report J9360 (Injection, vinblastine sulfate, 1 mg), says Matola.

Day 8: Check for Vincristine and Bleomycin

Staff typically administers two of the regimen's drugs on day 8.

Vincristine: Like vinblastine, vincristine is an alkaloid cell toxin. Brand names include Oncovin and Vincasar, Matola adds.

You should report it using J9370 (Vincristine sulfate, 1 mg), says Matola. Or if staff administers a larger dose, look to J9375 (Vincristine sulfate, 2 mg) or J9380 (Vincristine sulfate, 5 mg).

Bleomycin: The patient also receives intravenous bleomycin, an anti-tumor antibiotic, on day 8. Report this agent using J9040 (Injection, bleomycin sulfate, 15 units), says Matola. And keep an eye out for Blenoxane as another name, she says.

Day 15: Add Etoposide to Doxorubicin and Vinblastine

The typical day 15 routine is similar to day 1, but it's not exactly the same.

The patient again receives doxorubicin (J9000) and vinblastine (J9360), but does not receive mechlorethamine.

Instead, intravenous etoposide, a DNA toxin, is used. Etoposide is also called VePesid or Toposar, Matola says. You also may see the name Etopophos. Code J9181 (Injection, etoposide, 10 mg) represents this agent, she notes.

Day 16: Repeat Etoposide Infusion

On day 16, the patient receives another etoposide (J9181) infusion.

Day 22: Expect Same as Day 8

The drugs administered on day 22 are the same as day 8, with the patient receiving short infusions of vincristine (J9370, J9375, J9380) and bleomycin (J9040).

Everyday: Pay Attention to P.O. Prednisone

The final drug in the regimen is prednisone, a corticosteroid to help reduce inflammation. The patient typically takes this drug orally (abbreviated as p.o. for "per os," which means "by mouth"), daily or on alternate days. The patient may taper off of the drug at the end of the third cycle.

HCPCS does offer J7506 (Prednisone, oral, per 5 mg) to describe oral prednisone. But remember that CMS considers oral prednisone a self-administered drug and will not cover it under Part B. (See Medicare Benefit Policy Manual, chapter 15, section 50.5, www.cms.gov/Manuals/IOM/list.asp.)

On the other hand, if the provider administers the injectable form, such as J1030 (Injection, methylprednisolone acetate, 40 mg), you may be able to code the drug and administration. Medicare

Benefit Policy Manual, chapter 15, section 50.4.3, explains that Medicare doesn't cover a medication's injectable form if the oral route is standard and medically appropriate. But the manual indicates there could be an exception if special medical circumstances justify an injection rather than the oral form.

Watch for: Patients also may receive other reportable medications. For example, keep an eye out for anti-nausea medications such as Zofran, J2405 (Injection, ondansetron hydrochloride, per 1 mg), and Kytril, J1626 (Injection, granisetron hydrochloride, 100 mcg).

Final note: Only report the drug codes if you bear the cost of the drugs, and be sure to report the appropriate administration codes, as well.

In the next issue, learn more about choosing the appropriate ICD-9 codes for patients with Hodgkin's disease.