Oncology & Hematology Coding Alert

Plus: Allowed Anzemet units take a dive. Here's why.

If you're dealing with denials for sequential therapeutic infusions or anti-nausea medications, don't miss these two Medicare-related updates.

1. Decide How to Handle +96367 Claims

You're in good company if you've been wondering why you're getting denials for more than three units of +96367 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; additional sequential infusion of a new drug/ substance, up to 1 hour [List separately in addition to code for primary procedure]).

The cause is a medically unlikely edit (MUE) of 3 for the code, effective Jan. 1, 2012, as explained in Oncology & Hematology Alert, vol. 14, no. 3. An MUE is a frequency edit that applies to Medicare claims via the Correct Coding Initiative (CCI).

Good news: CCI will change the MUE for +96367, announced the Community Oncology Alliance (COA) on its website (http://communityoncology.org/article- Coding-Help-on-MUE-Relating-to-CPT-Code-96367.aspx).

The announcement quotes CCI medical director Niles Rosen, MD, as saying CCI "will make a temporary change in the MUE value for this code in the April 1, 2012, version. The change will be retroactive to January 1, 2012." Rosen indicated the new value would be unpublished, but it would be high enough to allow for examples provided by COA Administrators' Network members. (The quote also refers to the pre-April MUE as unpublished, but it has been available in the Practitioner Services MUE table published by CMS at www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp.)

The increased MUE is good news, but the change won't take place until April 1. That means you must decide how to handle claims for more than 3 units of +96367 until the change is effective. Rosen indicated that practices may do either of the following:

(1) Hold relevant claims until April 1 when payers will apply the increased MUE (because the change is retroactive to Jan. 1, the new MUE will apply to dates of service going back to that time).

(2) Send in claims now, and overcome the MUE edit, which is checked against each line individually, by reporting +96367 x3 on one line and then +96367-59 (Distinct procedural service) with up to an additional 3 units on a second line.

2. FDA Move Affects Anzemet Allowed Units

CMS is lowering the allowed units for intravenous and intramuscular Anzemet, long used to prevent nausea and vomiting in patients receiving chemotherapy.

Reason: The Food and Drug Administration (FDA) took a closer look at Anzemet's ability to cause heart rhythm problems. Based on the results, the FDA decided to add a contraindication to Anzemet's prescribing information stating "the injection form of Anzemet (dolasetron mesylate) should no longer be used to prevent nausea and vomiting associated with cancer chemotherapy (CINV) in pediatric and adult patients" (www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm237341.htm, posted Dec. 17, 2010).

"CMS has lowered the allowed units to comply with the contraindication of the IV/IM injection form," Palmetto GBA announced in its March 2012 Advisory for J1 Part B (page 23, www.palmettogba.com/Palmetto/Providers.Nsf/files/March_2012_Advisory_J1B.pdf/$File/March_2012_Advisory_J1B.pdf).

The change affects code J1260 (Injection, dolasetron mesylate, 10 mg). The number of allowed units was not included in the announcement, and you won't find J codes published in CMS's MUE table.

Don't miss: The FDA stated that physicians may still order an Anzemet injection to prevent and treat postoperative nausea and vomiting "because the lower doses used are less likely to affect the electrical activity of the heart and result in abnormal heart rhythms." Additionally, the physician may still prescribe Anzemet tablets for patients to prevent chemotherapy-induced nausea and vomiting because the oral form poses less risk to the heart than the injection form. Still, the FDA recommends not using the drug in patients with a variety of risk factors, such as heart issues, electrolyte imbalances, and renal impairment.