Oncology & Hematology Coding Alert

Not all anti-emetics are alike, and they should not be coded as such. Ondansetron is a drug that is indicated for use with chemotherapy drugs that are classified as highly emetogenic, causing nausea and vomiting. Oncology coders must know which drugs correspond with billing for Ondansetron (J2405, Q0179) to get adequately reimbursed. Coders should become familiar with the documentation criteria required when the drug is used with low emetogenic chemotherapy, as a first-line treatment (first drug used) or when used in its oral form.

Reimbursement becomes a problem with private insurance companies and HMOs, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinical director at the Tulane Cancer Center in New Orleans. They may have a pecking order in their formulary that requires oncologists to use other specific anti-emetics before Ondansetron can be used.

Some carriers require oncology practices to first use oral Ondansetron or a less expensive anti-emetic drug and for the patient to be unresponsive to these drugs before IV Ondansetron is covered.

Get Paid for IV Administration

When intravenous (IV) Ondansetron is used to combat nausea, code J2405 should be used to describe the drug, and 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the infusion of the anti-emetic. Medicare requires these codes be included on the same claim form as the administration (96410-96412 infusion technique, one to eight hours, each additional hour [list separately in addition to code for primary procedure]).

Intravenous Ondansetron is generally covered when administered on the same day as the following high-toxicity drugs:

Cisplatin J9060-J9062
Cytarabine J9100-J9110
Mechlorethamine J9230
Cyclophosphamide J9070-J9097
Doxorubicin J9000-J9001

Using the correct codes associated with these drugs is important because they provide the strongest evidence of medical necessity, says Phyllis Klein, who specializes in oncology coding and is president of P.K. Administrative Services, a medical billing agency in Lakewood, Colo.

Medicare also allows coverage in situations in which the patient has a history of not responding to standard treatment for nausea and vomiting associated with chemotherapy. This type of claim would be filed the same way. For example, when a patient returns to the office days after chemotherapy was given with symptoms of nausea, the payer is likely to reimburse for IV Ondansetron even though it did not occur on the same day as the chemotherapy. The payment is based on the use of highly emetogenic chemotherapy just days before, Klein says.

Coders should also be aware that separate payment is not allowed for the infusion of saline, or any other non-chemotherapy drug administered under 90780 and 90781 (each additional hour, up to eight hours [list separately in [...]