Coding Strategy

Don’t sweat reporting 38220-59 if you meet these Medicare-approved conditions.

If your oncologist takes both a bone marrow biopsy and a bone marrow aspiration, whether you’ll see Medicare reimbursement depends on the two guidelines below. But watch out: With OIG scrutiny and a HCPCS twist, these guidelines will put your coding savvy to the test.

Append 59 for Different Sites and Encounters

Because a bone marrow biopsy and a bone marrow aspiration can provide different diagnostic information for certain leukemia evaluations, taking both specimens from the same patient on the same day isn’t unusual, according to R.M. Stainton Jr., MD, president of Doctor’s Anatomic Pathology in Jonesboro, Ark.

Snag: Medicare and some other payers use the Correct Coding Initiative (CCI) edits to restrict how you bill for “sequenced” surgical procedures through the same incision. For biopsy and aspiration, CCI bundles the following codes:

• 38220 — Bone marrow; aspiration only
• 38221 — … biopsy, needle, or trocar.

Silver lining: You may report 38220 and 38221 together, according to the NCCI Policy Manual for Medicare Services, Chapter 5, Section E, if the physician performs the procedures at either of the following

• Different patient encounters
• Different sites, meaning “in different bones or two separate skin incisions over the same bone.”

For CMS and other payers who use the CCI edits, if these two procedures meet one of the above listed criteria, you may override the edit by appending modifier 59 (Distinct procedural service) to 38220 and receive payment for both services, Stainton says.

Additional 59 support: CMS posted “Modifier 59 Article: Proper Usage Regarding Distinct Procedural Service” on its CCI overview Web page. In the article, you’ll find the following examples, which echo the CCI manual criteria, of when CMS considers modifier 59 use to be appropriate for bone marrow aspiration and biopsy:

• Different sites: contralateral iliac crests; iliac crest and sternum
• Different incisions: same iliac crest
• Different encounters.

Beware: In one study, the Office of Inspector General (OIG) found that coders inappropriately used modifier 59 more often with 38220/38221 than any other code pair. So you want to take extra care to append modifier 59 only when appropriate. If the procedures occur through the same incision, you should not use modifier 59 to report 38220 and 38221 together to Medicare. For guidance on that situation, see the next section.

Capture Same Site With G0364

Medicare indicates you shouldn’t use modifier 59 to bill 38220 and 38221 together for a bone marrow biopsy and aspiration through the same incision. But that doesn’t mean you have no recourse.

Know the G code: For sequenced procedures, you’ll report 38221 for the biopsy as usual. Then you can also report the aspiration to Medicare using G0364 (Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service), says Joyce Matola, billing manager for The Center for Cancer and Hematologic Disease in New Jersey. So be sure to let the physicians know that you need documentation on the number of incisions and the specific sites involved.

Commercial payer caution: Contact your payer for specific coverage guidelines before submitting your claim for bone marrow aspiration and biopsy. Some commercial and managed care payers may have guidelines that allow you to report 38220 and 38221 for sequenced procedures. Others may require you to report only the most extensive procedure.

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Here’s the key to concurrent infusion coding.

Question: What are the appropriate codes for the first day of the FOLFOX4 regimen?

Answer: You should base your final coding decision on the documentation and the exact services your practice provides. But as a starting point, the FOLFOX4 regimen typically involves the patient receiving Oxaliplatin and folinic acid concurrently over two hours, followed by a 5-FU bolus on day one.

That same day, the patient begins a 22-hour infusion of 5-FU, often using an ambulatory pump. In this scenario, your day one claim would include:

• The Oxaliplatin (J9263, Injection, oxaliplatin, 0.5 mg) with 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and +96415 (… each additional hour [List separately in addition to code for primary procedure])
• The 5FU (J9190, Injection, fluorouracil, 500 mg) with +96411 (… intravenous, push technique, each additional substance/drug [List separately in addition to code for primary procedure])
• The concurrent folinic acid (J0640, Injection, leucovorin calcium, per 50 mg) with +96368 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; concurrent infusion [List separately in addition to code for primary procedure]).

Key to concurrent: CPT Assistant (November 2005) indicates that the concurrent infusion code is appropriate for multiple infusions provided through the same IV line.

CPT Assistant (November 2006) clarifies that “to report a concurrent administration, the drugs cannot simply be mixed in one bag; there must be more than one bag.” If the drugs are mixed in a single bag you would report a single administration code.

Additionally: If you also report the ambulatory pump initiation, use 96416 (Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion [more than 8 hours], requiring use of a portable or implantable pump).

@ Oncology Coding Alert

Want to become an oncology coding expert? Attend this ENCORE presentation of the 2010 Oncology Coding Update, presented by Brenda Chidester.

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Here are the requirements the exam must meet, according to Medicare.

If your PET claim meets certain requirements, you don’t need to append modifier Q0 (Investigational clinical service provided in a clinical research study that is in an approved clinical research study), according to MLN Matters article MM6753.

Effective for dates of service on or after Nov. 10, 2009, Medicare has an updated national coverage determination (NCD) for cervical cancer FDG PET imaging. Medicare has ended the coverage with evidence development (CED) requirements for initial staging of initial treatment.

Medicare will cover one FDG PET for cervical cancer. That one exam must meet specific requirements:

• The exam must be for staging (not initial diagnosis).
• The patient must have biopsy proven cervical cancer.
• The treating physician must need the study to determine the tumor’s location, extent, or both for one of the following therapeutic purposes related to initial treatment strategy:
• To determine whether the beneficiary is a candidate for an invasive diagnostic or therapeutic procedure
• To determine the optimal anatomic location for an invasive procedure
• To determine the tumor’s anatomic extent when the recommended anti-tumor treatment depends on that information.

Codes: Your claim must include all of the following for reimbursement:

• An appropriate CPT code from 78608 (Brain imaging, positron emission tomography [PET]; metabolic evaluation), 78811-78813 (Positron emission tomography [PET] imaging …), or 78814-78816 (Positron emission tomography (PET) with concurrently acquired computed tomography [CT] for attenuation correction and anatomical localization imaging …)
• Modifier PI (PET Tumor initial treatment strategy)
• A cervical cancer diagnosis code (such as 180.x, Malignant neoplasm of cervix uteri).

Action step: The effective date of this policy is Nov. 10, 2009, but the implementation date is Jan. 4, 2010. Carriers won’t search their files for PET cervical cancer claims for Nov. 10 to Jan. 3 dates of service, but they will adjust those claims that you bring to their attention.

Resources: To learn more, check out Transmittal 110, Change Request 6753.

@ Oncology Coding Alert

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Watch for your chance to replace 86316 with more specific 86305.

If your oncology practice has its own lab, heads up.

You’re sure to find a few new lab codes “in CPT 2010 that you need to know,” says Peggy Slagle, CPC, billing compliance coordinator at the University of Nebraska Medical Center in Omaha.

Get started with a look at these three codes you’re likely to use in your oncology/hematology practice.

Heed New HE4 Code, 86305 …

CPT 2010 adds ovarian cancer marker code 86305 (Human epididymis protein 4 [HE4]). “HE4 has been shown to be elevated in a great percentage of women with epithelial ovarian carcinomas,” says Brenda Chidester-Palmer, CPC, CCS-P, coding compliance manager of Kelsey-Seybold Clinic in Houston in her “2010 Oncology Coding Update” audio seminar.

The test helps monitor disease progression or recurrence, Chidester-Palmer adds. In an example provided by CPT Changes 2010: An Insider’s View, the patient has her HE4 level tested monthly during her chemotherapy encounter, and monitoring the level helps the oncologist determine that chemo was effective.

Bonus: This code change allows for “more specificity in reporting. For instance, you can use 86305 for HE4 starting Jan. 1 rather than using generic code 86316 (Immunoassay for tumor antigen, other antigen, quantitative [e.g., CA 50, 72-4,549], each) for the test,” points out William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.

Add 86352 for Cellular Immune Status Test

You also have a new transplant management immune function marker code: 86352 (Cellular function assay involving stimulation [e.g., mitogen or antigen] and detection of biomarker [e.g., ATP]).

Code 86352 describes a test that assesses cellular immune status as a measurement of cell-mediated immunity (CMI) in whole blood and assists in management of cancers, HIV, and autoimmune disorders, Chidester-Palmer says.

Confirm Method Before Choosing 88738

CPT 2010 also adds a new lab code for a test that can aid in anemia and transfusion management: 88738 (Hemoglobin [Hgb], quantitative, transcutaneous). Keep in mind that transcutaneous means “through unbroken skin.” This test involves a spectroscope device (hand-held, near-infrared) and eliminates the need to draw blood, Chidester-Palmer says. Code 85018 (Blood count; hemoglobin [Hgb]) remains appropriate for a hemoglobin test involving blood draw.

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Did you miss Brenda Chidester-Palmer’s update? Good news! We’re airing an encore!

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Watch those Taxotere units, or kiss 95 percent of your reimbursement goodbye.

A brand new list of HCPCS codes — including docetaxel and bevacizumab updates — goes into effect Jan. 1 and our 8-step superbill maintenance plan will stop denials in their tracks for 2010.

Not using the proper codes will lead to claim rejection, which means “not receiving the proper reimbursement. And no one wants to start out their new year that way,” points out Lisa Martin, CPC, CIMC, CPC-I, who oversees the charge operations for a large, independent community cancer center in central Illinois and is an active instructor for the AAPC’s Professional Medical Coding Curriculum.

1. Docetaxel Do: Swap J9170 for J9171

The most widely used of the new chemotherapy HCPCS codes may prove to be J9171 (Injection, docetaxel, 1 mg), says Martin. Oncologists may prescribe docetaxel (Taxotere) for breast cancer, non-small cell lung cancer, prostate cancer, gastric cancer, and head and neck cancers.

Units alert: HCPCS 2010 deletes 2009 docetaxel code J9170 (Injection, docetaxel, 20 mg). The main difference is how you’ll calculate units. In 2009, you reported 1 unit for every 20 mg. In 2010, you’ll report 1 unit per 1 mg. If you fall into old habits, billing 1 unit for every 20 mg, you’ll only get 5 percent of the reimbursement you’re due, warns Roberta Buell, MBA, in her Nov. 17 E-Reimbursement newsletter for OnPoint Oncology in Sausalito, Calif.

2. Focus on J9155 for Firmagon

Depending on your specialty, you may find J9155 (Injection, degarelix, 1 mg) useful in the new year, says Martin.Oncologists prescribe degarelix (Firmagon) for patients with advanced prostate  cancer.

As with the new docetaxel code, you’ll report 1 unit for every 1 mg of degarelix.

3. Choose J9328 for IV Temozolomide

New code J9328 (Injection, temozolomide, 1 mg) may be of more interest to certain practices, says Martin.

Temozolomide (Temodar) treats particular types of brain cancer, specifically glioblastoma multiforme (coded as a malignant neoplasm based on site) and refractory anaplastic astrocytoma (also coded as malignant neoplasm by site). Remember that J9328 is particular to the intravenous formulation, not the oral drug.

4. Say ‘So Long’ to Short Lived Q2024

Confusion abounded when CMS created Q2024 (Injection, bevacizumab, 0.25 mg), effective Oct. 1, 2009. Oncology coders already had J9035 (Injection, bevacizumab, 10 mg) for bevacizumab (Avastin).

The lower dosage amount (0.25 mg per unit) made Q2024 more appropriate for ophthalmologists who use smaller amounts. But their outcry about payment problems encouraged CMS to delete Q2024, bringing much cheering from oncology and ophthalmology coders alike.

Bottom line: In 2010, continue to use old faithful code J9035 for bevacizumab

5. Move Mozobil Coding to J2562

If you provide plerixafor (Mozobil) injections, be sure you highlight new code J2562 (Injection, plerixafor, 1mg). The FDA approved the drug in 2008 for patients with non- Hodgkin lymphoma and multiple myeloma. When combined with granulocyte-colony stimulating factor (GCSF), plerixafor stimulates stem cells to move out of the bone marrow and into the blood stream so the physician may collect the cells for later autologous transplant.

(“Autologous” means the cells are transplanted back into the same patient.)

Tip: The codes you may use for G-CSF include filgrastim (Neupogen) codes J1440 (Injection, filgrastim [G-CSF], 300 mcg) and J1441 (Injection, filgrastim [GCSF], 480 mcg). Ensure, however, that you choose the most appropriate code based on the strength ordered and administered according to the supporting documentation.

6. Add J2796 for ITP Patients

Practices treating patients for chronic immune (idiopathic) thrombocytopenic purpura (ITP) need to know about J2796 (Injection, romiplostim, 10 micrograms). Romiplostim (Nplate) stimulates bone marrow megakarocytes to produce platelets, helping ITP patients, who have lower than normal platelet counts.

7. Jump to J7185 for Xyntha in 2010

Xyntha antihemophilic factor will get an upgrade from temporary code Q2023 (Injection, factor VIII [antihemophilic factor, recombinant] [Xyntha], per I.U.) to new permanent code J7185, which has the same descriptor.

Because of this change, HCPCS 2010 deletes Q2023 and tweaks the descriptor for J7192, making it a “not otherwise specified” code:

• 2009: J7192 — Factor VIII (antihemophilic factor, recombinant) per IU

• 2010: J7192 — Factor VIII (antihemophilic factor, recombinant) per IU, not otherwise specified.

8. Separate Ferumoxytol Codes by ESRD Use

The iron containing product ferumoxytol (Feraheme) has two new temporary codes for 2010:

• Q0138 — Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)

• Q0139 — Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis).

Note that Q0138 is specific to non-end stage renal disease (non-ESRD) use and Q0139 is for ESRD patients on dialysis.

Currently, the drug has FDA approval for patients with chronic kidney disease. Interestingly, the drug also has potential as an MRI contrast agent and may prove useful in tumor imaging.

Remember: You can download the latest HCPCS file from the CMS Web site here.

AUDIO ON-DEMAND: 2010 Oncology Coding Update.

Oncology Coding Reference CD Collection for 2010.

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