Oncology & Hematology Coding Alert

Call on modifier KD to recoup drug costs

When coding for prolonged drug infusion via a portable or disposable pump, you must be sure to report all components of the service, from infusion initiation to supplies to ongoing pump maintenance. In addition, you-ll want to be sure that the available documentation meets the precise criteria payers require to support these services.
 
Begin With 96416

When the provider initiates prolonged infusion with a portable or disposable pump in the office, you will first report 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump).

-Code 96416 describes the nursing chemotherapy administration service for initiation of the portable infusion pump,- confirms Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in Cherry Hill, N.J.

To meet code requirements, the infusion (whether continuous or intermittent) must last a minimum of eight hours. Because the patient leaves the office for the duration of the infusion, -it is only possible to document the time of initiation, not completion- says Lisa S. Martin, CPC, CPC-INTMED, with Illinois CancerCare, P.C. -When the patient presents for the pump disconnect, the record should then reflect the time of disconnect.-

Additional documentation: -The medical records should include a treatment plan that indicates how long each pump should run,- Martin -- who is also an independent coding educator and consultant and AAPC-approved instructor -- continues. -In addition, it is helpful for each patient's record to contain a -pump recipe- documenting the cc's of the drug and any fluid additives, and stating the rate at which it should run.-

An example of nursing documentation for pump initiation might say: -Fluorouracil 3521 mg (at 2160 mg m/2)(of 50 mg/ml) intravenous once continuous over 46 hours in NS 96.6 ml. Start time June 26, 2008 13:50,- Matola offers.

Important: Medicare and other payers will not cover portable or disposable pump use for all medications. Generally, only those drugs (such as 5FU, J9190, Fluorouracil, 500 mg) that require long-term infusion to prevent tissue necrosis and other side effects will call for 96416.

In contrast, because providers may safely administer saline or heparin using standard infusion techniques, you would not report 96416 (which is reserved for chemotherapy) for these. If you administer non-chemotherapy drugs via pump, you must report an unlisted procedure code such as 90799 (Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion).

Call on E codes for Pump Supply

If your oncology practice rents or owns the portable pump that a patient uses for prolonged infusions, you may report an appropriate HCPCS code for the pump's cost to your DMERC.

For infusions of eight hours or more by a portable, external pump, you should select either E0779 (Ambulatory infusion pump, mechanical, reusable, for infusion eight hours or greater) for a nonelectric (mechanical) pump or E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient) for an electric pump.

In either case, the patient will carry the refillable pump with him for use outside the office. If, however, the patient uses the pump in the office only, you cannot report a separate E code for pump rental, according to Medicare and other payer guidelines, Martin stresses.

Tip: Do not confuse portable pumps with implantable pumps as described by supply codes E0782-E0786 range. Watch POS for Pump, Supplies
 
You should list the place of service (POS) for all DME codes (in this case, the portable pump), as the patient's home, Martin reminds.  -This is a common mistake,- Martin continues. -Although the pump -initiation- [96416] takes place in the office, you should report the pump, drug(s) and supplies with POS 12 [Home].-

Claim Ongoing Maintenance
 
Portable pumps require periodic refilling and maintenance, which you may report separately using 96521 (Refilling and maintenance of portable pump), Matola says. Do not report the initial infusion code (96416) for subsequent infusions using the same pump.

-When a patient's pump has been completely dis-connected, and he or she presents for another infusion, you may use 96416,- Martin clarifies. But, -when the pump has not been disconnected and the patient presents only for a refill, you would use 96521.-

Note that Medicare and other payers will pay for pump refill and maintenance only for a previously-covered pump that meets medical necessity requirements. In other words, if Medicare wouldn't cover an initial infusion (96416), they will not cover refilling and continued maintenance.

You should call on A4221 (Supplies for maintenance of drug infusion catheter, per week [list drug separately]) each week for supplies used for maintenance of the epidural catheter port, including site dressings and flush solutions not directly related to the drug infusion, Martin says.

In addition, you may also report A4222 (Infusion supplies for external drug infusion pump, per cassette or bag [list drugs separately]) for the supply cost for each bag or cassette that you provide the patient.
 Payment alert: Be aware that many payers will not reimburse you for supply codes A4221 and 42222.

Don't Forget Drug Supplies

You should of course report an appropriate supply code for all drugs the provider infuses by portable pump. Just as important, however, is that you should append modifier KD (Drug or biological infused through DME) to all supply codes for drugs administered via an infusion pump.

Why it matters: CMS pays DME-administered drugs at a higher rate than those infused another way (such as injection).

Consider E/M Billing Possibilities

Be aware that you would not normally report an E/M service for the same encounter as initiation of infusion or pump refilling and maintenance.

Only if the patient required a separately identifiable evaluation (for instance, for a new complaint or a due to a change in status that requires a significant workup) would you report an additional E/M service.

-There are many times that our patients are seen for an E/M visit prior to initiation of a portable pump. As long as proper documentation supports the E/M visit, you may bill for it,- Matola says.

In such a case, you should be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M service code to signal to the payer that the E/M service was -above and beyond- the inherent E/M component of the same-day infusion initiation or pump refill and servicing.

Lastly, most payers (including Medicare) will consider disconnection of the pump at the end of the infusion period to be an incidental component of the infusion initiation (96416). It's worth your time to check on this, however, because some payers may allow you to report the disconnection separately with a low-level E/M service code (99211, Office or other outpatient visit for the evaluation and management of an established patient-).