Oncology & Hematology Coding Alert

Why assigning chemo codes 96400-96459 isn't always your best bet You can strengthen your Faslodex (fulvestrant) administration claims if you use up-to-date drug codes, document the metastatic cancer, report a therapeutic injection, and code per monthly dose. Learn New J Code to End Unclassified Confusion In January 2004, CMS ended nearly two years of confusion and debate among oncology coders when it introduced J9395 (Injection, fulvestrant, 25 mg) as the new code for Faslodex.

Before J9395, oncology coders argued about whether to assign J9999 (NOC [Not otherwise classified] antineoplastic drug) or J3490 (Unclassified drugs) for Faslodex. But many practices used J3490 because drug companies required the code and because the drug is an estrogen receptor antagonist, says Lisa C. Wood, office manager at Cancer Center of the Piedmont in Danville, Va. On the other hand, some insurers paid only for J9999.

Now, however, you should assign J9395 when the oncologist or nurse provides Faslodex to postmenopausal women who have metastatic breast cancer that has not responded to anti-estrogen therapy, Wood says. You'll Need to Use Primary and Secondary ICD-9 Codes Drugmakers intended Faslodex to treat postmenopausal women with certain kinds of breast cancer. But your oncologist may also use the drug to treat male breast cancer patients.

For instance, private and Medicare carriers, such as First Coast Service Options of Florida, cover both male and female breast cancer patients. So, your oncologist can use the following ICD-9 codes as the primary diagnosis, when appropriate: 174.0-174.9 -- Malignant neoplasm of female breast
175.0-175.9 -- Malignant neoplasm of male breast. Because some therapies, such as Faslodex, require a metastatic breast cancer diagnosis to qualify for coverage under most payer plans, the documentation should list a secondary diagnosis code, says Cheryl Bilton, CPC, billing manager, Regional Hematology Oncology Associates in Langhorne, Pa. This secondary code represents the site where the cancer has spread. Your ICD-9 coding options may include: 196.0-196.9 -- Secondary and unspecified malignant neoplasm of lymph nodes
197.0-197.8 -- Secondary malignant neoplasm of respiratory and digestive systems
198.0-198.8 -- Secondary malignant neoplasm of other specified sites. Keep Your Chemo, Therapeutic Codes Straight Many breast cancers have estrogen receptors that stimulate tumor growth. The physician or nurse injects Faslodex into the patient to reduce estrogen receptors. Therefore, drugmakers classify Faslodex as a hormonal drug.

This means you should assign therapeutic injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular), Wood says. Problem: Many oncology coders mistakenly believe that if a drug has a chemotherapy-related J code (J9000-J9999), they must assign a chemotherapy administration code (96400-96549) when reporting the therapy. Solution: Remember to list a chemotherapy administration code only when the physician or nurse uses [...]