Oncology & Hematology Coding Alert

Spring is here, bringing helpful changes for oncology and hematology coders. CMS has issued two new change requests that will affect your anti-emetic reimbursement and erythropoiesis stimulating agent (ESA) coding. Let our experts give you the view from the trenches on what you can expect from these revisions.

If you-re submitting Medicare claims for anti-emetics administered to cancer chemotherapy patients, get ready to see more money back on some of your submissions.

Effective April 4, hospital outpatient departments can bill Medicare for the entire so-called tri-fold pack of oral anti-emetics, according to CR 5655.

Physicians administer this combination as part of a cancer chemotherapeutic regimen that's based around Aprepitant, a substance P antagonist. They administer Aprepitant along with a 5-HT3 antagonist -- such as Dolasetron, Granisetron or Ondansetron, for example -- and Dexamethasone, a cortico-steroid.

CMS issued this revised version of CR 5655 to correct information in the original MLN Matters version, according to Janae Ballard, CPC, CPC-H, CPC-E/M, ACS-EM, revenue coding analyst at the Virginia Mason Medical Center in Seattle.

"The clarification better explains the requirements of billing for the oral three-drug combination," Ballard says. "It clearly states that all three drugs must be given and billed together."

What to do: CMS says that you should report the tri-fold pack as 57 units of J8501 (Aprepitant, oral, 5 mg).

Remember: You-ll only receive reimbursement for these oral anti-emetics when the provider uses them as a full therapeutic replacement for intravenous dosage forms as part of a cancer chemotherapeutic regimen. Your physician has to prescribe or administer the drugs for use immediately before, at or within 48 hours of the chemotherapeutic agent administration time, CMS says.

CMS also notes that that some Medicare contractors have been known to deny payment for the entire tri-fold pack because physicians send two of the doses home with the patient.

Be alert: You-ll want to stay on top of your coding game when you-re dealing with this drug combination. "This could potentially cause reimbursement problems," Ballard says, but only if a patient does not receive all three of the drugs required for this anti-emetics combination.

You can find the complete text for CR 5655 on the CMS Web site at http://www.cms.hhs.gov/transmittals/downloads/r1281cp.pdf.

Along with the anti-emetic guideline changes, CMS has also issued a revision to an MLN Matters article on CR 5818 that may affect coding ESAs in cancer and related neoplastic conditions.

This clarification corrects a mistake in the original wording in MLN Matters MM5818, Ballard says. The amendment to one of the key points now matches the CMS National Coverage Determination (NCD) that was originally published July 2007. The implementation date for the latest revision is April 7, 2008, says Joyce Matola, billing manager for the Center for Cancer and Hematologic Disease in Cherry Hill, N.J..

The change: The revised article corrects one of the factors CMS uses to determine whether "ESA treatment for the anemia secondary to a regimen of myelosuppressive anticancer chemotherapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia is reasonable and necessary." The revised factor states, "Maintenance of ESA therapy is the starting dose if the hemoglobin level remains below 10 g/dL (or hematocrit is < 30 %) 4 weeks after initiation of therapy and the rise in hemoglobin is > 1 g/dL (hematocrit > 3 %)."

What this means for you: CR 5818 creates a lot of work for oncology coders, Matola says. "Each ESA claim must contain the most recent hemoglobin or hematocrit level," she says, noting that this "was a CMS requirement in the past that had been discontinued."

"Further," Matola says, "each ESA claim line must also contain a modifier." She says that these include modifiers EA (Erythropoietic stimulating agent [ESA] administered to treat anemia due to anticancer chemotherapy), EB (Erythropoietic stimulating agent [ESA] administered to treat anemia due to anticancer radiotherapy) and EC (Erythropoietic stimulating agent [ESA] administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy).

According to CMS, claims including ESAs that were processed between July 30, 2007, and Dec. 31, 2007, don't have to include the ESA modifiers because these modifiers weren't effective until Jan. 1, 2008.

Keep these in mind: The HCPCS codes for non-end-stage renal disease (ESRD) ESA use are J0881 (Injection, darbepoetin alfa, 1 mcg [non-ESRD use]) and J0885 (Injection, epoetin alfa [for non-ESRD use], 1000 units). These codes cover Aranesp and Procrit, respectively.

For the full description of the revision to CR 5818, visit the CMS Web site at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5818.pdf.