Oncology & Hematology Coding Alert

Medicare has made code 96545 (provision of chemotherapy agent) virtually useless because it won't pay for the service separately from chemotherapy administration. But some commercial payers still pay for providing and administering the drug and reimburse for the drug itself. So, oncology practices should continue to consider billing drug provision with commercial payers.   Choosing a Billing Option    Medicare will pay for 96545 separately only if oncology practices use it instead of the J9xxx code for reporting the chemotherapy drug -- for example, if you bill 96545 with 96408 (chemotherapy administration, intravenous; push technique). However, if you want to get paid for each service, you cannot report the drug (for example, doxorubicin, J9000-J9001). How to bill becomes a bit more obvious when you consider that chemotherapy drugs cost hundreds -- if not thousands -- of dollars and 96545 pays less than $100 and isn't even required on the claim form for drug administration. For most practices, reporting 96408 and the appropriate drug code is the preferred option.    For all intents and purposes, Sharon Grimes, CPC, insurance and billing manager for the West Clinic, an oncology practice in Memphis, Tenn., finds 96545 useless.  "We don't use the code for Medicare or commercial payers," she says, "because we have no problem getting paid for chemotherapy administration." Even though Grimes doesn't bill the code, she believes it's in a practice's best interest to check its carriers about accepting 96545 along with the chemotherapy administration and drug codes, and whether they will pay all three separately.
  Nancy Giacomozzi, office manager specializing in oncology practices with P.K. Administrative Services, a medical billing firm in Lakewood, Colo., thinks differently. "You can still get a handful of (commercial) carriers who are still paying for 96545. That's anywhere from $50 to $75. In my opinion, it's something I'm not ready to give up."
  
Billing Chemotherapy Components   Medicare describes chemotherapy services in three parts -- physician services, preparation of agent, and chemotherapy administration. Medicare contends that reimbursement for chemotherapy administration includes both drug preparation and drug administration. Potentially, however, you can bill commercial carriers for three components of chemotherapy treatment:  
  1. Physician service -- includes obtaining history, performing a physical evaluation, prescribing appropriate drugs, educating the patient about the drugs and side effects; reviewing lab tests; and monitoring for drug side effects. Use 99211-99215 (office or other outpatient visit for the evaluation and management of an established patient) to report these services.
  2. Preparation of the agent -- includes obtaining the agent, calculating the amount needed and compounding the agent in the medium, maintaining records, and ensuring proper disposal of supplies and refuse. Report 96545.   3. Administration -- includes placing and maintaining temporary venous access, and using and maintaining [...]