Oncology & Hematology Coding Alert

Scoop: Here's the latest on what these changes mean for your office

The upcoming reimbursement cuts to chemotherapy drug and administration codes take effect in 2005, but there's no time like the present to get ready for these changes.

CMS' shift from the Average Wholesale Price to an Average Sales Price reduces payment for 32 chemotherapy drugs and administration codes in 2005, which could cost oncology practices a purported $500 million in 2005. Here's a breakdown of estimated, preliminary payment rates for commonly used drugs and codes, according to the American Society of Clinical Oncology (ASCO). Follow Guidelines When Reporting Rituximab When your oncologist or nurse administers Rituximab, you should assign J9310 (Rituximab, 100 mg) for the drug, says Lisa C. Wood, office manager at Cancer Center of the Piedmont in Danville, Va.

You can expect to lose nearly $25 a pop when you report J9310, which drops from $438 to $413. Oncologists usually give Rituximab to patients with B-cell non-Hodgkin's lymphoma or leukemia whose cancers have not responded to other chemotherapy regimens.

Most Medicare payers, such as Empire Medicare Services in New York, require that your oncologist administer the drug through intravenous infusion, not the push technique, if you operate out of an outpatient setting.  

This means when you report J9310, you will likely assign 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour) for the first hour, and +96412 (... infusion technique, one to 8 hours, each additional hour [list separately in addition to code for primary procedure]) for one to eight hours, Wood says.

Warning: CMS began to scrutinize the coding and billing of Rituximab earlier this year after it reviewed 100 claims, finding that 55 percent had been inappropriately billed, according to CIGNA Healthcare Medicare Administration. And with your practice standing to lose $25 for each J9310 billed next year, you don't want to lose even more because you incorrectly reported the code.

What to do: When you assign J9310, make sure you follow these coding and documentation guidelines:

1.  The patient has finished a "front line" or initial treatment of chemotherapy. Medicare pays for Rituximab when used for relapsed or refractory cancers. Payers may also reimburse one course of Rituximab during initial treatment if the physician administers in combination with another anti-cancer drug.

2. The cancer should be CD20 positive, which Medicare requires in the treatment of refractory different types of non-Hodgkin's lymphoma and leukemia.

3. Documentation records appropriate dosage. Generally, Medicare carriers require oncologists to give Rituximab in 375mg/m2 weekly doses for four weeks.

4. You must report a covered diagnosis. The best way to ensure that you're listing an appropriate ICD-9 code is to check with your insurer.

For instance, Medicare carrier HGSAdministrators would accept a physician diagnosis of [...]