There are times when most oncology practices come across a treatment, drug or supply item that is so new it has not yet been assigned a code. In such cases, the pro-viders should use a code that best resembles the procedure or use codes for unlisted procedures, drugs and supplies.

The disadvantage of the first route is that it can produce payment that is not adequate for the time and resources used during the procedure, or for the cost of the drugs or supplies used. On the other hand, using a code for unlisted items opens the door to denials and increased paperwork, not to mention audits and repayments later.

The emphasis on using existing codes for unclassified items is stressed by coding manuals as well. HCPCS, for example, instructs providers that the unclassified codes such as J9999 should be used only if a more specific code is unavailable. Used prudently, however, codes for unassigned items and procedures, such as CPT 96549 (unlisted chemotherapy procedure) and HCPCS J9999 (unclassified, antineoplastic drug), can yield payment that best reflects the resources used.

You want to supply an exact CPT code, says Daniel L. Johnson, director with Health Care Consultants of America, an Augusta, GA-based coding consulting firm, whose clients include oncology practices. Even though there are 9,000 CPT codes, you cant always find one that fits exactly. And even though payment may be difficult to get when you use unassigned codes, there are times when you have to.

Unassigned Codes Determined by Route
of Administration

Until a new chemotherapy drug is given a specific
J-code, its given a not otherwise classified code according to the route of administration:

1. Unclassified chemotherapy drugs, such as Herceptin, administered by other than oral means (intravenous, intramuscular, subcutaneous) are coded as J9999.

2. Unclassified oral chemotherapy drugs, such as Xeloda, are coded as J8999.

3. Unclassified supportive drugs, such as anti-emetic medications, are classified by route of administration.

Three Tasks Crucial to Getting Paid

When oncology practices must choose a code for an unassigned procedure or medical item, Johnson says, they often neglect to perform three tasks to ensure proper payment:

1. Get prior clarification from the insurer. Maximizing reimbursement with codes for unassigned items requires communication between the provider and payer prior to any new procedure or use of new drugs or supplies, says Johnson.

Get an understanding from the carrier before the procedure is done, he says. A written explanation should be sent to the insurer explaining that the physicians office will be performing a procedure or using a drug that is now without a CPT or HCPCS code. Along with the letter, Johnson says, the provider should send current literature that describes the efficacy of the drug in similar situations.

2. Document medical necessity. Documenting medical necessity is an important component in garnering proper payment. Including documentation requesting prior clarification from the insurer as part of your submission will go a long way to getting pre-approval to use an unclassified code.

None of these catch-all codes (such as J9999) refers to a quantity or dosage, unlike the codes for specific drugs (such as code J9100, cytarabine, 100 mg; or J9110, cytarabine, 500 mg). Thus the claim must include a narrative specifying the medical necessity for each of the drugs used and the quantity of each. Additional supporting documentation should include a minimum of two journal articles supporting the use of the drug in the quantity used for the particular indication. Many pharmaceutical manufacturers have reimbursement assistance programs that can aid you in this process. Contact information for these manufacturers can be found on the Association of Community Cancer Centers Website: www.assoc-cancer-ctrs.org/.

Since some drugs have been tested effective for limited types of situations, make sure that the diagnosis code supports the use of the situation for which the drug is considered effective. For example, Herceptin is approved only for breast cancer and must have diagnosis codes such as V10.3 (personal history of malignant neoplasm, breast) or 174.0-174.9 (malignant neoplasm of female breast). (See article on off-label use of drugs in box on page 5.)

Note: Its important to remember that information supplied by pharmaceutical manufacturers may reflect a vested interest and, therefore, may not be viewed as objectively as information from other sources.

Finally, correspondence with the insurer should include the actual invoice for the drug or item used. If it is a procedure that is in question, the physicians office should include the list of supplies to be used to help the insurer or fiscal intermediary determine cost.

Investing extra work up front in documenting the medical necessity for new drugs and procedures can save time in the long run, according to Kim Ransier, RN, senior consultant, KR Johnson & Associates, a full-service practice management and billing consulting firm specializing in oncology, in Coeur dAlene, ID. If we know its a new drug or treatment and theres no code and the office hasnt billed for it before, we often suggest sending a paper claim with the appropriate documentation the first few times it is billed.

Heres why: If you send a claim electronically, reimbursement takes about a week. A paper claim can take up to 30 days. So most billers will say that it makes more sense to send it electronically. But if you send it electronically, you cant attach the appropriate articles, so the claim may be denied and sent back. Then it usually sits on someones desk for a while before she or he has time to research the claim and refile it properly. So it actually can take longer by the time you walk the claim through the process after the fact than if you just sent a paper claim initially.

3. Follow up on the paid claim. Making a prior arrangement with the insurer will spare the practice from providing documentation of medical necessity when the bill is submitted. All that is left is for the practice to follow up on the claim to be sure it is actually paid, and in full. But the practices hardly ever follow up, laments Johnson.

Once payment is received, billing managers should compare the payment to the total cost as evidenced by invoices and resources used to deliver the service, he advises. Too often, practices just submit the claim and forget about it, Johnson says.

Experimental Drugs, Procedures Not Covered

It should be noted that the above advice does not necessarily apply to experimental drugs. If an insurer has classified a drug or procedure as experimental, the chances of being reimbursed are slim. Instead, providers should focus on using codes for unassigned items in cases where the drug is characterized as new but is backed by either journal articles that provide evidence of efficacy or has been recently approved by the Food and Drug Administration.

According to the Coverage Issue Manual (CIM), some drugs and biologicals that are distributed by the National Cancer Institutes Division of Cancer Treatment are covered, although unclassified. Specifically, this includes agents designated as Group C drugs, which means they are not limited to use in clinical trials for testing efficacy within a tumor type and they can be safely administered.

There are, however, four guidelines for a physician to be eligible to seek payment using J9999 in cases where a drug is experimental:

1. A physician must be registered with the National
Cancer Institute (NCI) as an investigator, having completed an FD-Form 1573;

2. a written request for the drug must be submitted to
the NCI, indicating the disease to be treated;

3. use of the drug must be limited to indications
outlined in NCI guidelines; and

4. all adverse reactions must be reported to the Investigational Drug Branch of the Division of Cancer Treatment.

In turn, the CIM advises practices that they may assume the uses of Group C drugs are covered as long as the above requirements are met.