Oncology & Hematology Coding Alert

Chemotherapy drugs are expensive, and if you-re not billing the unused portions of drugs your practice supplies, you-re losing out.

What to do: Under Medicare rules, you often may receive reimbursement for wasted drugs simply by listing the amount of leftover drug, with an appropriate modifier, on line 24 of the CMS-1500 claim form.

To report drugs the oncologist actually administers to a patient, you should select the appropriate HCPCS supply code (such as J9206, Irinotecan, 20 mg) and list that code in box 24D of the CMS-1500 claim form. You will bill for drugs only if your practice actually purchases and provides the drug, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.

Occasionally, the oncologist may have to discard an unused portion of a drug. Many drugs have a short "shelf life," and if the physician does not empty an open vial within, for instance, an eight-hour period, she may have no choice except to throw the remaining supply away.

For example, during infusion the patient may have an allergic reaction. Although most of the drug supply remains unused, the infusion had begun and you cannot use these supplies for another patient. You must, therefore, "waste" the remaining drug. Quick tip: In the case of a terminated infusion due to patient reaction, your payer may prefer you to include an additional diagnosis code such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Adverse effect, antineoplastic drug) to describe the circumstances of the service.

Medicare and other payers will reimburse your practice for wasted drugs, but only for drugs supplied in "single-use vials," notes Jean Acevedo LHRM, CPC, CHC, president of Acevedo Consulting Inc. in Delray Beach, Fla.

The oncologist may treat more than one patient from a single-use vial, but she must use the drug within a short time.

By contrast, a "multiuse vial" generally treats a larger number of patients, and may be used without "spoilage" over a greater time period. Medicare and other payers will not cover wasted drugs from multiuse vials.

If the oncologist must waste a portion of a single-use vial, you should list on the claim form both the amount of the drug the physician administered and the amount she discards. Most payers prefer that you list these as two separate line items.

Example 1: The provider administers 125 mg of oxaliplatin (J9263, Injection, oxaliplatin, 0.5 mg), using three 50-mg single-dose vials. Note that each 50-mg vial contains 100 billable units (each billable unit is 0.5 mg).

In this case, you would report J9263 in box 24D of the CMS claim form.

In the "units" box, you would enter "250." On the next line, you-d list J9263 with "50" in the units box to describe the wasted drug amount (three 100-dose vials = 300 ��" 250 administered units = 50 wasted units).

In addition, you would append modifier JW (Drug amount discarded/not administered to any patient) to the wasted units (box 24G of the CMS-1500 form) to identify for the payer that the oncologist discarded these units and did not administer them to the patient.

Example 2: A patient with metastatic colorectal cancer (154.0, Malignant neoplasm of rectum, rectosigmoid junction, and anus; rectosigmoid junction) presents for palliative chemotherapy (96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug). The provider administers 350 mg/m2 irinotecan intravenously in 500 mL D5W (5 percent dextrose in water) over 89 minutes.

To report the drug supply, you should call upon J9206 (Irinotecan, 20 mg). Remember to factor in the 20 mg included in the descriptor when you calculate your units.

In this case, the oncologist uses nine 40-mg vials (360 mg) -- he administers 340 mg irinotecan and wastes the remaining 20 mg. If you divide the drug amount the provider administers (340 mg) by the size of the dose (20 mg), you end up with 17 billable units (J9026 x 17). You should report the remaining 20 mg (1 unit) as waste. Be sure to append modifier JW to J9206 x 1.

Tip: If the oncologist uses a single-dose vial for multiple patients, you should assign any discarded supply to the last patient on whom you use the single-dose vial.

For example, if the oncologist uses 45 units of a 100-unit vial for patient A and 45 units on patient B, with 10 discarded units, you-d charge 45 units to patient A and 45 units plus 10 wasted units for patient B.

Remember: You should never report waste on multi-dose vials.

Go to the source: You can find Medicare regulations for reporting discarded drug supplies in the Medicare Claims Processing Manual, Chapter 17, available at http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf.