Oncology & Hematology Coding Alert

An oncologist may prescribe a combination of drugs for non-Hodgkin's lymphoma patients. And if your practice bears the drugs' cost, that means you have multiple HCPCS codes to report correctly.

Case in point: The CHOP regimen involves four drugs, requiring you to determine the proper codes, the proper units, and even whether you should report each drug. Learn from the experts as they walk you through the CHOP essentials.

The letters in CHOP stand for the following, says Kelly Loya, CPC-I, CPhT, senior consultant with Los Angeles-based Sinaiko Healthcare Consulting:

• C: cyclophosphamide

• H: hydroxydaunomycin (doxorubicin HCl)

• O: Oncovin (vincristine)

• P: prednisone.

The clinical team often administers CHOP over a number of cycles. For example, the patient may receive treatment every 21 days, with prednisone taken over five days, for six cycles.

Cyclophosphamide is an alkalizing chemotherapy agent that disrupts cancer growth.

You should report administration with the appropriate chemotherapy administration code, says Shelly Noll, CPC, with radiation and oncology at Rockwood Clinic in Spokane, Wash.

HCPCS offers the choice of several cyclophosphamide codes.

The first code is J9070 (Cyclophosphamide, 100 mg), which is appropriate for 100 mg or less. Tip: The HCPCS manual indicates this code is appropriate for Endoxan-Asta, which isn't marketed in the U.S.

The other cyclophosphamide codes include the following, says Loya:

• J9080 -- Cyclophosphamide, 200 mg

• J9090 -- Cyclophosphamide, 500 mg

• J9091 -- Cyclophosphamide, 1 g

• J9092 -- Cyclophosphamide, 2 g.

The HCPCS manual states that you should use the above codes for Cytoxan and Neosar.

You have a separate set of options for lyophilized cyclophosphamide, Loya notes:

• J9093 -- Cyclophosphamide, lyophilized, 100 mg

• J9094 -- Cyclophosphamide, lyophilized, 200 mg

• J9095 -- Cyclophosphamide, lyophilized, 500 mg

• J9096 -- Cyclophosphamide, lyophilized, 1 g

• J9097 -- Cyclophosphamide, lyophilized, 2 g.

The above codes are appropriate for Cytoxan Lyophilized, the HCPCS manual indicates.

Hydroxydaunomycin is also a chemotherapy agent -- specifically an anthracycline antibiotic -- and is also a vesicant.

A vesicant can seep into the tissue if it escapes the vein, so the nurse must be very watchful, says Tricia Katzberg, RHIT, CPC, CCS-P, with Cancer Care of the Cascades in Oregon. If the drug does seep into the tissue, it can cause severe tissue damage.

You should report administration with the appropriate chemotherapy administration code, says Noll.

The appropriate HCPCS code for hydroxydaunomycin is J9000 (Injection, doxorubicin HCl, 10 mg), Loya says.

Other names you may see for this drug are Adriamycin PFS, Adriamycin RDF, and Rubex.

Tip: HCPCS includes another doxorubicin code, J9001 (Injection, doxorubicin HCl, all lipid formulations, 10 mg).

But the drug this code represents, Doxil, is intended for ovarian cancer, and oncologists sometimes use it to treat other solid tumors.

Oncovin is another chemotherapy agent (a plant alkaloid) and vesicant. Again, you should choose from the chemotherapy administration codes, says Noll. HCPCS includes the following codes for Oncovin, Loya says:

• J9370 -- Vincristine sulfate, 1 mg

• J9375 -- Vincristine sulfate, 2 mg

• J9380 -- Vincristine sulfate, 5 mg.

Codes J9370 and J9375 describe Oncovin and Vincosar PFS. Code J9380 is appropriate for Oncovin, the HCPCS manual indicates.

The final element of CHOP is prednisone, which is a corticosteroid, Loya says. HCPCS includes J7506 (Prednisone, oral, per 5 mg) to describe the oral form typically used for the CHOP regimen.

Caution: Physician coders should not report the oral prednisone for Medicare patients because CMS considers it a self-administered drug, and it is "not on the list of medications allowed to be reported under the Part B jurisdiction and incident to a physician's service, according to CMS," Loya says.

But if the provider administers the injectable form -- for example, J1030 (Injection, methylprednisolone acetate, 40 mg) or J1040 (Injection, methylprednisolone acetate, 80 mg) -- you may be able to code the drug and administration, choosing the admin code based on the route and administration time, Loya says.

Key: The 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 an exception if special medical circumstances justify an injection rather than the oral form.

Try your hand at coding this example, including HCPCS codes and units, and the appropriate administration code. Assume that none of the administration times overlap.

Also, remember that according to Chapter 17 of the Medicare Claims Processing Manual, if the dose isn't a precise multiple of the dose in the HCPCS descriptor, you should round to the next highest unit.

Here's the example, provided at a single encounter:

• Doxorubicin, 50 mg/m2 by IV push on day 1

• Vincristine, 1.4 mg/m2 by IV push on day 1

• Cyclophosphamide, 750 mg/m2 by IV infusion in 100 mL normal saline over 45 minutes on day 1

• Prednisone, oral, 100 mg/m2 on days 1 through 5.

Solution: For the cyclophosphamide infusion, choose one unit of initial infusion code 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the administration and one unit of J9091 for the drug.

For the doxorubicin administration, report +96411 (Chemotherapy administration; intravenous push technique, each additional substance/drug [List separately in addition to code for primary procedure]). Report the drug with 5 units of J9000.

Code +96411 is also appropriate for the vincristine, and 1 unit of J9375 covers the drug.

You shouldn't report the oral prednisone on the claim.