Wiki Aloxi Diagnosis - Please Help!

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CFisher5

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I am having a problem with some of my commercial insurance companies. We get J2469 X 10 units authorized with the chemo therapy code. Then we bill, and they deny for the diagnosis. If the note states that the patient was have nausea with vomiting I can go back and change the primary diagnosis to 787.01, and the secondary diagnosis is the chemo diagnosis. However, this drug is also given for the prevention of nausea/vomiting during chemo and if they do not currently have that problem, it is not documented in the note. I do not feel comfortable billing a diagnosis code that I can not locate in the note. Is it ok to bill this diagnosis if I can show that there is a pattern of nausea with vomiting, even though the patient does not have it on this specific date? Or, is there something different that the doctor/nurse should be documenting in the chemo record to allow for the billing of this diagnosis? I know some insurance companies require specific diagnosis for certain drug, but I refuse to put a diagnosis on a claim that I can not logically justify. But, I still want to get the payment that should have been easily processed and sent to us (especially when we had to call and get a pre-auth for the drug and they approved it using the cancer diagnosis but then turn around and deny the claim for the same diagnosis that they approved it for in the first place!!:mad:)

Thanks to anyone who can help!! :D
 
Aloxi

We use the cancer dx and as far as I know all is good.

I do however have an LCD for this drug for Regtion 4 Alabama ( not me, but I kept it for the info. I could not find one for my region). L30033 2009
Indication :
1. Prevention of acute nausea and vomiting with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy.
2.Prevention of delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy
3. Preention of postoperative nausea and vomiting for up to 24 hours following surgery
ICD9 Codes that Support Medical Necessity
V07.8 For Preventio of post-operative nausea and vomiting up to 24 hours following surgery
E930.7 Antineoplastic antibiotics causing adverse effects in therapeutic use
AND THIS ONE'S FOR YOU.....:)
E933.1 Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
 
Aloxi

Hi,

When we request prior authorization we use the cancer code but when we send the claim we use code 787.01 and we have gotten paid. I know some also may use 787.01 with V58.11.
I hope this helps :D
 
For Highmark and Coventry... they are not accepting the cancer diagnosis. I have been working with my biller to do some appeals with 787.01 as the primary diagnosis and the cancer diagnosis as the secondary (with notes stating the patient's nausea and vomiting and the drug sheet from the company stating the reason why the drug is given). Knowing insurance companies they will probably deny because the cancer diagnosis should be first followed by 787.01... But I know Medicare wants us to bill it with V58.11, 787.01, cancer dx... so I am taking a chance. I will let you know how it plays out in case anyone else has problems with this.
 
CFisher5 said:
I am having a problem with some of my commercial insurance companies. We get J2469 X 10 units authorized with the chemo therapy code. Then we bill, and they deny for the diagnosis. If the note states that the patient was have nausea with vomiting I can go back and change the primary diagnosis to 787.01, and the secondary diagnosis is the chemo diagnosis. However, this drug is also given for the prevention of nausea/vomiting during chemo and if they do not currently have that problem, it is not documented in the note. I do not feel comfortable billing a diagnosis code that I can not locate in the note. Is it ok to bill this diagnosis if I can show that there is a pattern of nausea with vomiting, even though the patient does not have it on this specific date? Or, is there something different that the doctor/nurse should be documenting in the chemo record to allow for the billing of this diagnosis? I know some insurance companies require specific diagnosis for certain drug, but I refuse to put a diagnosis on a claim that I can not logically justify. But, I still want to get the payment that should have been easily processed and sent to us (especially when we had to call and get a pre-auth for the drug and they approved it using the cancer diagnosis but then turn around and deny the claim for the same diagnosis that they approved it for in the first place!!:mad:)

Thanks to anyone who can help!! :D
Click to expand...

In Michigan, we bill with the Cancer DX as primary code, 787.01 as the secondary code unless the insurance carrier is Blue Care Network who wants the Cancer DX Primary code, V58.11 as the secondary dx code. We do have a few ins carriers who also want the Cancer dx & V58.11. But we never bill with 787.01 or V58.11 as the primary code. Not sure if this helps, but good luck with your issue.
 
For anyone who is still needing help with this issue here is the result of my investigation:

Medicare in our region requires V58.11, 787.01, Cancer dx

All other carriers are requiring us to bill the cancer dx, 787.01 on the drug AND the admin code. I did have to submit notes with some of my claims and they originally came back as 'Not Medically Necessary' because the patient did not have N/V on that date. However, I did appeal based of the chemo drug given (it was a highly emetogenic drug) and the indications and usage listed in the prescribing information (have the pdf saved on my computer) and they did reverse that and pay the code.

The V codes/E codes were not accepted by any of the commercial insurance companies so unfortunately I could not use any of them. I was nervous about using 787.01 on patients that did not currently have N/V but the insurance companies are telling me that they want the diagnosis for what the drug is preventing on the claim.
 
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