Leorah Posted Thu 30th of January, 2020 15:34:30 PM
Our doctors performed a lumbar puncture with intrathecal chemotherapy administration and as instructed by Supercoder in the past I coded this as a 96450 and 77003. The 77003 was paid by Aetna but the 96450 was denied and on the EOB it said "The chemo administration codes were not billed with nonradionuclide anti-neoplastic drugs, anti neoplastic agents used for treatment of non-cancer diagnosis, monoclonal antibody agents and other immunomodulator drugs. Please do not bill the patient." I have successfully billed this code many times in the past but this response on the EOB makes me wonder if we are missing something with our ICD-10 or CPT coding. We submitted a C83.30 and M51.36 as the diagnosis coding
SuperCoder Answered Fri 31st of January, 2020 04:20:48 AM
As per the CMS guidelines, chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as certain monoclonal antibody agents, and other biologic response modifiers.
In above mentioned codes drug code is missing. The HCPCS Level II establishes “Injectable Chemotherapy Drugs” as those in the range of codes J9000-J9999. Infusions of drugs with assigned HCPCS codes in this range are accepted as appropriately billed using the chemotherapy administration codes (CPT® codes 96401-96549).
Please check the report for the drug administered and code accordingly.
Note: Medicare and some other payers may require HCPCS Level II code Q0083, Q0084, or Q0085 be reported for this service. Check payer guidelines to determine which codes the payer accepts for chemotherapy administration.
Please check the below link:
Leorah Posted Wed 05th of February, 2020 15:45:09 PM
Are supposed to code the drug with a HCPCS code even if it falls on the facility and not our provider to charge for the drug?
Leorah Posted Thu 06th of February, 2020 04:04:12 AM
When I showed our doctors the link from your response attached above they stated that the CMS link pertains to IV drugs not Intrathecal. The procedure that was performed on the patient was with an intrathecal chemotherapy administration.
SuperCoder Answered Thu 06th of February, 2020 04:06:12 AM
The CMS link pertains not only for IV drugs, it is also applicable for Intrathecal. These guidelines are applicable for the codes which are ranges from 96401 to 96549, which also includes 96450.
As per the CMS guidelines, Claims that are billed with the chemotherapy administration CPT codes 96401-96549 that do not have an associated drug in claim history, will deny. When the administration claim is processing, an allowed claim for the drug must be present, either on a prior claim or on the same claim as the administration.
Leorah Posted Thu 13th of February, 2020 09:09:51 AM
We are not allowed to legally bill for the drug. We are only allowed to bill for the professional administration. There is a coinciding claim that is coming from the hospital . Should we be getting pushback from the insurance if we have only billed for the professional administration of the drug?
SuperCoder Answered Fri 14th of February, 2020 08:27:37 AM
Our team is working on it and will get back to you.
SuperCoder Answered Mon 17th of February, 2020 05:49:16 AM
Thanks for your patience.
You should bill administration code and specify the drug or substance that was given, if the specific code is not billed on the claim. You can also approach insurance to clarify the coinciding claim that is coming from the hospital.
There may be a possibility that hospital was also billing on the behalf of physician for drug administration, in this case physician fee (for drug administration) will be given by hospital.
Hope this helps!
SuperCoder Answered Tue 18th of February, 2020 00:12:16 AM