Coding Strategy

Remember to describe all the circumstances surrounding a push to get full reimbursement.

Question: If a non-Hodgkin’s lymphoma patient has an adverse reaction to Rituximab less than 15 minutes into the ordered hour-long infusion, should I report a push?

Answer: Experts suggest the most appropriate way to report a discontinued infusion is to append modifier 53 (Discontinued procedure) to the appropriate chemotherapy infusion code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

You should use modifier 53 when a physician stops a procedure “due to extenuating circumstances or those that threaten the well-being of the patient,” according to CPT.

Modifier 53 describes an unexpected problem, beyond the physician’s or patient’s control, that necessitates ending the procedure. The physician doesn’t elect to discontinue the procedure as much as he is forced to do so because of the circumstances.

Push: CPT guidelines include “an infusion of 15 minutes or less” as one definition of a push, but 96413-53 describes the ordered and provided service more accurately than a push code (such as 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug).

HCPCS: Your documentation should describe the circumstances, the administration start and stop times, and the amount of drug delivered and discarded. If you’re coding for the drug (J9310, Injection, rituximab, 100 mg), you should be able to report the entire amount, assuming you discarded the amount not administered.

ICD-9: Remember also to report the appropriate ICD- 9 codes, such as V58.12 (Encounter for antineoplastic immunotherapy) and 202.8x (Other lymphomas), and a code to indicate why the procedure stopped, such as V64.1 (Surgical or other procedure not carried out because of contraindication) or E933.1 (Drugs, medicinal, and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs).

Also watch for E/M services performed to care for the patient.

@ Oncology & Hematology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

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Whether liver neoplasm is primary or secondary will change your coding.

Good news: You can apply many of the same rules you already know for intravenous chemotherapy coding to intra-arterial coding, too. So take your chemo coding expertise to the next level by adding intra-arterial skills to your arsenal.

Start here: For intra-arterial (IA) chemotherapy, you should choose from the following codes, says Gwen Davis, CPC, associate with Washington-based Derry, Nolan, and Associates.

• 96420 — Chemotherapy administration, intra-arterial; push technique
• 96422 — … infusion technique, up to 1 hour
• +96423 — … infusion technique, each additional hour, (List separately in addition to code for primary procedure)
• 96425 — … infusion technique, initiation of prolonged infusion (more than 8 hours), requiring use of a portable or implantable pump.

Compare 96420-96425 Applications

Push: For an IA chemotherapy push, you should report 96420, says Davis. You should apply the same CPT definitions for a “push” to both IA and intravenous (IV) administration:

(a) “an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient”

OR

(b) “an infusion of 15 minutes or less.”

Infusion: For infusion by temporary catheter, a physician often places the catheter into the artery supplying blood to the tumor. Infusion code 96422’s definition specifies “up to 1 hour,” and +96423 specifies “each additional hour.” But just as with IV infusion codes, CPT indicates you should report the “additional hour” code “for infusion intervals of greater than 30 minutes beyond one-hour increments,” Davis says. So if the infusion lasts one hour and 30 minutes, you should report only 96422 (without adding +96423) because the time has not reached the “greater than 30 minutes” required for +96423.

Pump: Infusion by pump is a common method of intra-arterial administration. Report 96425 for prolonged infusions that require a portable or implantable pump and last longer than eight hours. This code describes only the initial service, so if your practice performs refilling or maintenance, you should choose the appropriate code from 96521-96523, just as you would for an IV pump service. Keep in mind: For Medicare and other payers whose contracts indicate they process claims according to National Correct Coding Initiative (CCI) logic, be sure to follow the guidelines in CCI Manual, chapter 11, section N.5 (www.cms.gov/NationalCorrectCodInitEd). The manual states you shouldn’t report 96521-96522 alongside 96425 because 96425 includes “the initial filling and maintenance of a portable or implantable pump.”

Focus on Liver For Likely Diagnoses

Two of the more common diagnoses treated by IA chemotherapy are primary liver neoplasm and a secondary liver neoplasm that metastasized from the colon. To learn more about your diagnosis coding, subscribe to the Oncology Coding Alert. Editor: Deborah Dorton, JD, MA, CPC

Sign up for the upcoming live audio conference, Take the Sting out of Coding Infusion and Injection Services, or order the CD/transcripts.

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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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