Oncology & Hematology Coding Alert

Physician offices in 10 western and midwestern states no longer are able to list more than one diagnosis code per procedure on their claim form the result of new requirements that took effect Oct. 1. Listing more than one code will result in claim denial, according to the Health Care Financing Administration (HCFA). The new rule applies to providers in Arizona, Colorado, Hawaii, Iowa, Nevada, North Dakota, Oregon, South Dakota, Washington and Wyoming.

Although the edict seems simple one procedure equals one diagnosis code there are a number of oncology-related procedures and drugs that require more than one diagnosis code to prove medical necessity.

For example, Ethyol, an organic thiophosphate cytoprotective agent given to patients with advanced ovarian cancer (183.0) or nonsmall cell lung cancer (162.2-162.9) who are being treated with the chemotherapy drug Cisplatin (J9060, J9062), requires more than one diagnosis code. For most oncology practices, the failure to list both codes will result in claim denial.

Indications and limitations for coverage set forth by Medicare state that Ethyol is indicated only for coverage to reduce the cumulative renal toxicity associated with repeated administration of Cisplatin in patients with advanced ovarian cancer and nonsmall cell lung cancer.

When Two Diagnosis Codes Are Needed

For most providers to get paid for the use and administration of Cisplatin, codes 183.0 or 162.2-162.9 must appear along with the procedure code on the claim form. In addition, a secondary diagnosis code 995.2 (unspecified adverse effect of drug, medicinal and biological substance) must be listed. Because both are integral components to prove medical necessity, providers in the states affected by the Medicare changes have questioned which to use and whether the absence of one will lead to denials or prompt carriers to audit claims.

We have gotten a lot of calls about this, says Barbara Benson, a customer service representative for Noridian Mutual Insurance Co., the Medicare carrier for Arizona and Colorado. People have been asking what to do when there needs to be two diagnosis codes.

Filling Out the Claim

According to HCFA, providers in the 10 states listed above should adhere to the following steps when filling out a claim form:

1. For item 24e, enter the diagnosis code reference number, as shown in item 21, to relate the date of services and the procedures performed to the primary diagnosis.

2. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service, a 1, 2, 3 or 4.

3. For each CPT code, enter the number of that services primary diagnosis code from item 21. In other words, do not enter 1 and 2, or 1 through 4, even if multiple diagnoses for the CPT code apply. Link each line with only one diagnosis code.

4. If a situation arises where two or more diagnoses are required for a procedure code, you must reference only one of the diagnoses from item 21.

According to Benson, providers shouldnt worry about listing a second diagnosis if both diagnosis codes are referenced in item 21. In most cases, the cancer diagnosis code is the correct choice, Benson says. Whoever is reviewing the claim also will view the codes referenced in item 21 and will be able to determine whether the procedure was medically necessary.

Select the Code That Best Describes the Procedure

The American Society of Clinical Oncology (ASCO) agrees with Benson. ASCO says providers should choose the code that best relates to the procedure.

For example: When a supportive-care drug, such as Ethyol, is used on the same day as the chemotherapy drug Cisplatin, item 21 likely would reference the following diagnosis codes:

183.0,
995.2 and
V58.1 (encounter or admission for chemotherapy).

Included in the procedures as drugs the practice can bill for are:

Chemotherapy administration, 96410;

Cisplatin, J9060, J9062;

Therapeutic or diagnostic infusion for Ethyol, 90780 with -59 modifier (distinct procedural service) to
show sequential drug administration. (Ethyol is normally administered over a 15-minute period and 30 minutes prior to chemotherapy administration);

Ethyol, J0207;

Therapeutic or diagnostic injection for antiemetic, 90782; or

Ondansetron, J2405.

According to both Noridian and ASCO, the proper way to code for this sequence of drugs and procedures would be to list the three diagnosis codes in item 21, referencing them as: 1) 183.0; 2) 995.2; and 3) V58.1.

On line 24e, which is reserved for the reference numbers that correspond with the diagnosis codes listed in item 21, the reference number 1 can be used for all of the above procedures. In this situation, 1 refers to the primary diagnosis, ovarian cancer.

Codes 995.2 and V58.1 in item 21 will be cross-referenced against the procedure code and primary diagnosis code to verify medical necessity. In addition, ASCO says oncology practices would be safe to choose the closest related diagnosis code.

For instance, cancer codes are not the most closely related code for ondansetron because it is used to treat nausea, albeit chemotherapy-related nausea. In the above example, oncology practices can choose V58.1 as the single code associated with 90780 and J2405.