Oncology & Hematology Coding Alert

Question: We hear a lot about needing to choose an ICD-9 code that proves medical necessity for the oncological service the physician provides. What exactly does medically necessary mean?


Tennessee Subscriber
Answer: Medicare Transmittal 24 sets out the rule that contractors should consider a procedure reasonable and necessary if the procedure is safe and effective, not experimental, and appropriate. Unfortunately, these are all pretty subjective, so you should look up you payer's local policies to determine which ICD-9 codes support medical necessity for a specific CPT code.

Trial exemption: Medicare does provide an important exemption to the "not experimental" factor for medical necessity. Clinical trial services that meet the requirements of the Clinical Trials National Coverage Determination are reasonable and necessary. (Find the clinical trial rules at www.cms.hhs.gov/coverage/8d.asp.)

Keys carriers look for when deciding if a procedure is appropriate, including duration and frequency, comprise the following:
  furnished according to accepted medical-practice standards for diagnosis and treatment of your particular patient's condition
  performed in a setting appropriate for that patient
  ordered and performed by qualified providers
  meets, but doesn't exceed, patient needs
  is at least as beneficial as existing alternatives.
 
Moneymaker: For many oncology services, payers only cover one unit per course of treatment, but thorough chart documentation could mean a bigger payoff. If the oncologist orders additional simulation or treatment devices, for example, you should be able to code these more than once if he documents medical necessity due to tumor size or composition change, developing resistance to certain drugs, or treating an additional volume of interest. Provide a detailed explanation with the second report of the code and remember to have enough documentation to feel confident during an audit.

Boost reimbursement chances: Cite published study results supporting the oncologist's choice.