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J Oncol Pract. 2010 May; 6(3): 159–160.
PMCID: PMC2868644

Need Coding or Reimbursement Assistance?

ASCO has offered coding and reimbursement assistance to members for more than 10 years. Staff in the Practice Division of the Cancer Policy and Clinical Affairs Department respond to oncology-related coding, reimbursement, and coverage questions, and many times, additional resources, policies, and educational materials are provided. This service was originally available through a dedicated telephone line and e-mail address. As of March 1, 2010, the coding and reimbursement service has moved to a new electronic format, and inquiries must be submitted online at http://www.asco.org/billingcoding. Some recent questions posed to the service are provided:

Question 1:

How do you code a bone marrow aspiration and bone marrow biopsy from one puncture wound?

Response:

If a bone marrow aspiration and bone marrow biopsy are both performed at the same time, Medicare payment policies vary depending on whether the procedures are performed through the same incision or different incisions. If an aspiration is performed with a bone marrow biopsy on the same date through the same incision, Medicare policy states that the aspiration should be identified with code G0364. Code G0364 is billed in conjunction with the bone marrow biopsy code (38221).

If the biopsy and aspiration are performed through different incisions or in different patient encounters on the same day, then Medicare will make a separate payment for both procedures. When billing for both the bone marrow aspiration (38220) and bone marrow biopsy (38221) codes on the same date of service, the -59 modifier is required. In these cases, payments will be made for both procedures. Documentation in the medical record should support the billing. Private payers may not enforce such strict guidelines on these two procedures. Physicians should verify the policy of each payer.

Question 2:

Does the 21% cut in the conversion factor apply to office visits and chemotherapy drugs?

Response:

The Medicare Physician Fee Schedule includes all services and procedures performed by physicians and other health care professionals. It does not include drugs, labs, or durable medical equipment. Therefore, the 21% cut would apply to office visits and drug administration services but would not apply to the drugs themselves.

It is important to note that ASCO staff make every effort to provide helpful information and resources; however, ASCO is not responsible for the coding of any claim. The information provided through the service is not intended to maximize reimbursement by any payer. Reimbursement for medical products and services is affected by numerous factors and can vary among payers, plans, and patients.

The ASCO coding and reimbursement service provides general information about coding and reimbursement issues related to oncology services. The information provided is solely from publicly available resources, including the Centers for Medicare & Medicaid Services and ASCO's Practical Tips for the Oncology Practice. ASCO staff are not coding and billing consultants.

It is always the responsibility of the provider to determine and submit the appropriate codes, charges, and modifiers for products or services rendered. Providers should contact third-party payers for specific information on their coding, coverage, and payment policies. Information provided through the billing and reimbursement service should not be construed as an endorsement by ASCO of any product or service.

Question 3:

Can J1440 Neupogen (filgrastim; Amgen, Thousand Oaks, CA) be reported with chemotherapy administration code 96401?

Response:

The drug/substance filgrastim is classified as a colony-stimulating factor and is also identified as a human granulocyte colony-stimulating factor. The preamble to “Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration” in the Current Procedural Technology manual states that “substances such as certain monoclonal antibody agents, and other biologic repose modifiers” may be used with the chemotherapy administration codes.1

Some Medicare contractors have published lists of drugs that can be reported with the chemotherapy administration codes. Providers may want to verify with their private payers and Medicare contactors whether filgrastim is one of the accepted drugs that can be reported with these codes.

Question 4:

Where can I find more information on the US Pharmacopeia (USP) 797 and learn whether the standards are enforced in my state?

Response:

The USP establishes standards for compounding medicines in Chapter 797, entitled “Pharmaceutical Compounding—Sterile Preparations.”2 These standards are designed to help prevent harm to patients and employees. The standards do not take the place of the Occupational Safety and Health Act but can be adopted by government authorities (such as state boards of pharmacy and private accrediting organizations). Providers can find details regarding state enforcement at http://www.clinicaliq.com/797-state-survey. This link will identify the degree to which each state may be enforcing or following USP 797.

Coding, coverage, and reimbursement assistance is available to ASCO members and their staff free of charge as part of their benefits package. To access this service, visit http://www.asco.org/billingcoding and enter the ASCO member number into the electronic form. ASCO staff will receive the inquiry and provide a response via e-mail. Nonmembers can also access the service for a nominal fee.

If you have a question, please submit it at http://www.asco.org/billingcoding. If you have a topic you would like to see covered in an upcoming Practical Tips article, submit it to gro.ocsa@ksedsrotidepoj.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

References

1. Chemotherapy and other highly complex drug or highly complex biologic agent administration, in CPT Manual, American Medical Association. http://www.icd9interactive.com/reader/article_print/55540.
2. US Pharmacopeia. Guidebook to Pharmaceutical Compounding—Sterile Preparations; chapter 797. http://www.usp.org/products/797Guidebook/

Articles from Journal of Oncology Practice are provided here courtesy of American Society of Clinical Oncology