Wiki Oncology question

[Renee Willis]

Oncology Question
Need clarification on the proper way to code for infusion of the drug Heception J3955,
96413 for 1:30 minutes of infusion.
DX: Breast Cancer

Scenarios one
The reason for the encounter is for infusion of the herceptin drug for a one time visit.
Scenarios two
The reason for the encounter is for infusion of the herceptin drug for a series of visits
Should the diagnosis be?
V58.11
1749

Or
V58.69
174.9

Or
174.9
V58.69

Some supporting documents
Coding Clinic, Third Quarter 2009, page 3 and 4
States you should assign code 174.9 malignant neoplasm for the female breast, unspecified, as the first listed diagnosis, since Herceptin is considered cancer treatment. Assign code V58.69, long term use (current) use of Herceptin. It also states that Herceptin therapy is not antineoplastic chemotherapy, but is a biological adjuvant treatment for women with breast cancers that are HER2 positive

 

[mitchellde]

The coding clinic is correct. Herceptin is not chemo it is a biologic response modifier. We always coded it as the 174.9 with the V58.69.

 

[relong]

Herceptin is an antineoplastic drug which is also a monoclonal antibody, which is a fairly newer treatment concept in fighting cancer. It basically attaches itself to the HER2/neu receptor cells and prohibits them from proliferating, in addition to priming the patient's own immune system for attacking those specific malignant tumor cells.

It IS considered a chemotherapy agent by industry standards. It is coded as a J9000 code by the American Medical Association listed under injectible chemotherapy drugs.

While there are shades of gray in the world of oncology, with many policies and procedures being open for interpretation, my recommendation would be to use the V58.11 with the use of Herceptin.

You should also be coding to the greatest specificity for breast cancer and only be using 174.9 if theres no other option. The coding clinic you are referencing is outdated.

 

[lpetrova]

A couple of things I would like for you to clarify -

Did you mean J9355 (J9000 is for Doxorubicin)?​

I was told at some point that "all the -mabs (which includes Herceptin) must be coded with V58.12". I've never been able to find anything in writing on this. Do you have in mind any reference source, that will give me a better understanding why V58.11 needs to be used instead of V58.12.​

Thank you -

 

[hnroberts]

Lioubov -
I think what Ruth was trying to say was that all the J9XXX codes (J-Nine thousand codes) and not necessarily J9000 (Adriamycin) were considered chemotherapy drugs. As far as the V58.12 is concerned, you are probably correct regarding the -mabs, it would be the most specific code to use. As long as the V58.69, which is the LEAST specific code, is not used as suggested in the initial post, I think it's ok.
Have a great rest of the week!

 

[duncheart]

Herceptin is an antineoplastic drug which is also a monoclonal antibody, which is a fairly newer treatment concept in fighting cancer. It basically attaches itself to the HER2/neu receptor cells and prohibits them from proliferating, in addition to priming the patient's own immune system for attacking those specific malignant tumor cells.

It IS considered a chemotherapy agent by industry standards. It is coded as a J9000 code by the American Medical Association listed under injectible chemotherapy drugs.

While there are shades of gray in the world of oncology, with many policies and procedures being open for interpretation, my recommendation would be to use the V58.11 with the use of Herceptin.

You should also be coding to the greatest specificity for breast cancer and only be using 174.9 if theres no other option. The coding clinic you are referencing is outdated.

RUTH: Would you know the most recen coding clinic? I could not find anything after the one quoted in this string. Please let me know.