HCPCS 2011 Impacts Cisplatin, Cyclophosphamide, and Vincristine

This year's HCPCS codes show a number of deletions, streamlining your drug coding choices. The drugs that are affected this time are cisplatin, cyclophosphamide, and vincristine

This year's HCPCS codes show a number of deletions, streamlining your drug coding choices. All these changes should simplify billing, more so if the system your practice or facility uses limits you to a single code and billable unit for a drug.

Even though these changes have a positive side, there are considerations that will crop up. Say for instance you'll need to be alert for the different and specific national drug code (NDC) numbers for the agent dispensed to the patient when you send a claim to a payer who requires NDC information.

The drugs that are affected this time are cisplatin, cyclophosphamide, and vincristine. Cisplatin is one of the many agents impacted by the HCPCS 2011 shake-up. This year's HCPCS will make a small wording revision to J9060. Last year it read, J9060 -- Injection, cisplatin, powder or solution, per 10 mg. Now it reads, J9060 -- Injection, cisplatin, powder or solution, 10 mg.

What's more, you will no longer be able to use code J9062 (Cisplatin, 50 mg) this year. Instead, you should now use J9060 to report cisplatin, brand name Platinol, when supplied for 2011 DOS.

Cyclophosphamide is an alkalyting agent that works as an antineoplastic and immunosuppressant. So at 1 unit per 100 mg, J9070 won the role of the single option for coding cyclophosphamide injection supply. HCPCS this year deletes codes J9080, J9090, J9091, J9092, J9093, J9094, J9095, J9096 and J9097.

One more antineoplastic affected by the HCPCS revisions is cytarabine, which works to stop DNA replication. HCPCS 2011 keeps the code for the liposomal form: J9098. Apart from this, You also still have one code for the non-liposomal form (Cytosar-U): J9100. HCPCS however deletes the other non-liposomal code, J9110.

Dacarbazine is an antineoplastic. HCPCS 2011 keeps 100 mg code J9130 while it deletes 200 mg code J9140.

As far as Vincristine Codes are concerned, codes J9375 and J9380 Join the deleted list. This year you'll be reporting vincristine per milligram. Code J9370 is still valid this year but you will no longer be able to report larger increments using J9375 or J9380.

When it comes to topotecan, you'll see a swap of one J code for another this year. You should use just-in code J9351 for this topoisomerase type I inhibitor. You should use new code J9351 for this topoisomerase type I inhibitor. But you should no longer report code J9350.

For more on the HCPCS code changes, sign up for a one-stop HCPCS code lookup guide like Supercoder  which comes with a HCPCS code lookup tool to assist you in your coding.

MUE Denials? Here's How to Avoid Them

See to it that you are not letting MUEs play havoc on your practice's coding and reimbursement by keeping these things in mind.

You should not ignore medically unlikely edits; and even if you have to do it, do it at your own risk.

Medically unlikely edits often confuse even the most seasoned coders. See to it that you are not letting MUEs play havoc on your practice's coding and reimbursement by keeping these things in mind.

Know what MUEs are

Any practice that files a claim with Medicare should be aware of what MUEs are and how they function. MUEs were developed by CMS to reduce paid claims error rates in the Medicare program. One should not let every denial go because the insurance company said it was an MUE. The medically unlikely list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay.

The agency updates the MUE list every quarter but it does not publish all MUEs, especially those with values of four or higher.

Don't use ABNs to transfer responsibility for payment to the beneficiary

Remember that you cannot use ABNs to transfer responsibility for payment to the beneficiary. CMS makes this rule very clear in its FAQs: A provider or supplier may not issue an ABN for units of service in excess of an MUE.

Can you override an audit?

According to CMS, MUEs reflect the maximum number of units the vast majority of properly reported claims for a particular code would have; as such you are not required to override them often. However you can override an MUE when your doctor performs and documents a medically necessary number of services that go past the limit.

You need to check your payer's reporting preference: HCPCS offers modifier GD, however there's little information available on the correct use of this modifier. According to CMS, modifiers 76 and 77 are among your options to override an MUE as are the anatomical modifiers, such as RT. You may also use modifier 59 but you need to use this only if no other modifier is appropriate.

You can appeal an MUE denial

If you get a claim denial owing to MUEs, you can appeal. You can appeal the claims and you can address queries regarding the rationale for an MUE.

Tip: Inspect your explanation of benefits (EOBs) to look for remark code N362, which represents “the number of days or units of service exceeds our acceptable maximum" and may mean your claim has fallen afoul of the medically unlikely edits.


For more tips on mutually unlikely edits, sign up for a one-stop medical coding guide like Supercoder.

Get Your Rightful Reimbursements for FOBT

Here's a scenario to help your understanding of fecal occult blood test (FOBT) if you want to keep the dollars flowing.

Want to keep the dollars flowing for in-office examination of fecal occult blood test (FOBT)? Here's a scenario that will help your understanding:

A 60 year old patient presented in the office complaining of diarrhea preceded by intestinal cramping, which lasted for two weeks. He has no history of cancer in the family and did not feel nauseous at all. The doctor took a stool sample to test both parasites and blood. How should you go about this situation?

Report the proper code for each type of collection

Since 2007, CPT has assigned two codes that you can use for post digital rectal exam (DREs) and consecutive specimen collection: 82270 and 82272.

From January 1, 2007, CPT terminated HCPCS code G0107 and replaced by 82270 even for routine Medicare screening FOBT.

Remember that in the above scenario, it is not clear whether the doctor examined the samples himself or sent them to the lab. But then, as a general practice, parasite exams almost always take place in the lab. In this instance, the lab would be paid for the test directly.

Also ask the reason for the test. The keyword that can lead you to the proper CPT for FOBT is ‘why'. There do not hesitate to find out the reason your gastroenterologist has ordered it. If the test is for screening purposes, then you should use 82270. The ICD-9 code for screening hemoccults should be V76.51.

Do not forget: There are interval limitations for screening established by Medicare and most commercial carriers. Conversely, if a patient presents to the office with symptoms, the gastroenterologist would carry out a diagnostic FOBT, and you should bill it with 82272. CPT 82272 can be billed if 1 to 3 specimens are obtained. The diagnosis code for the test would be related to the patient's presenting symptoms.

For further details and for other medical coding updates, sign up for a medical coding guide like Supercoder.

HCPCS - Don't Use Modifier SA for Medicare Patients

You should use HCPCS Level II Modifier SA for Supervised Nurse Practitioner Services when the Insurer does need Modifier SA.

The Nurse Practitioner (NP) provides unsupervised services. Following this, I bill the codes under the nurse practitioner's number for supervised visits, I use modifier SA. In such a scenario, would I bill using the rendering or the supervising provider's NPI? Will payers reduce payment for a supervised visit?

Well, you should use HCPCS Level II modifier SA (Nurse practitioner rendering service in collaboration with a physician) for supervised nurse practitioner services when the insurer does need this modifier. Some Medicaid programs such as Medi-Cal require you to apply modifier SA to all nurse practitioner (NP) services which are submitted under the physician provider number. You should not use this modifier for Medicare patients as this modifier is not covered or valid for Medicare and therefore payments may be denied.

Here's an example to help you in your understanding: A nurse practitioner provides a level three established patient office visit to a Medi-Cal patient. The nurse practitioner's urologist supervises the service. To show the nurse practitioner provided the office visit under direct supervision, you would add modifier SA to 99213.

For incident-to services that are billed under the supervising physician's NPI number go for modifier SA. The modifier tells the insurer that the nurse practitioner rather than the physician provided the service and the physician supervised the nurse practitioner. Incident-to services are paid at 100 percent of the Medicare Physician Fee Schedule amount.

Insurers may apply a reduction to services billed directly under the nurse practitioner's NPI. Normal reduction here is 15 to 20 percent.

So you haven't heard of modifier SA is it? Well, HCPCS Level II created the HIPAA compliant modifier to standardize Nurse Practitioner reporting. For instance, before February 2009, Medi-Cal previously used modifier YT (Nurse practitioner service [multiple modifiers]).

For further details, sign up for a one-stop medical coding guide like Supercoder .