Oncology question

[Renee Willis]

Oncology Question
Need clarification on the proper way to code for infusion of the drug Heception J3955,
96413 for 1:30 minutes of infusion.
DX: Breast Cancer

Scenarios one
The reason for the encounter is for infusion of the herceptin drug for a one time visit.
Scenarios two
The reason for the encounter is for infusion of the herceptin drug for a series of visits
Should the diagnosis be?
V58.11
1749

Or
V58.69
174.9

Or
174.9
V58.69

Some supporting documents
Coding Clinic, Third Quarter 2009, page 3 and 4
States you should assign code 174.9 malignant neoplasm for the female breast, unspecified, as the first listed diagnosis, since Herceptin is considered cancer treatment. Assign code V58.69, long term use (current) use of Herceptin. It also states that Herceptin therapy is not antineoplastic chemotherapy, but is a biological adjuvant treatment for women with breast cancers that are HER2 positive

 

[uma gudipudi]

I code it as 174.9 and V58.11

 

[Renee Willis]

I code it as 174.9 and V58.11

Hi Uma thanks for responding to this question. Can you help me understand this better? So you would use V58.11 for antineoplastic chemotherpay, even though coding clinic states that Herceptin is not an antineoplastic chemotherapy drug but a biological adjuvant treatment for women with breast cancer. Coding guidelines state that V58.11 is an after care code for the encounter for antineoplastic chemotherapy and v58.69 is used for long term drug use if a patient is receiving a medication for an extended time or a disease requiring a lengthy course of treatment such as cancer. I am not an Oncology coder so any explanations would be appreciated. Thank you

 

[Ruth Sheets]

This topic is being considered for a topic in upcoming Q&A webinar topic - hopefully the next one. Meanwhile, please feel free to add your replies and comments to this thread.

 

[Alicia Scott]

These are great questions guys. I appreciate you posting them because it benefits so many. Another great one for the webinar as Ruth stated.

 

[Ruth Sheets]

This post was answered during the October 2012 Q&A Webinar. Your may view the replay of this video, as well as all the replays from the past, when you join the CCO Club. For more information, click here.

 

[Ruth Sheets]

Question: “I need clarification on the proper way to code for infusion of a drug Herceptin, J3955, 96413 which are CPT codes for 1 hour and 30 minutes of infusion. The diagnosis is breast cancer and the scenario is the reason for the encounter is for infusion of the Herceptin drug for a one-time visit.

Alicia: The second scenario, the reason for the encounter is for the infusion of the Herceptin drug for a series of visits. So you have the same thing going on, the difference is you’ve got a one-time visit and you’ve got a series of visits. So should the diagnosis be and those V codes, the V58.11 is actually a code for coming in often. The 174.9 is the cancer code, if you didn’t know.

Laureen: Yes, so V58.11 is encounter for anti-neoplastic chemo, the 174.9 is the unspecified breast cancer and the V58.69 is long-term current use of other medications.

Alicia: The patient is not coming in for the cancer. They’re coming to their visit to have an infusion. So that’s going to be your first code. So that should have been a heads up to not put the cancer code first.
We’ve got an IV infusion of chemotherapy which is that’s what the medication that we gave you was for one hour and 30 minutes. Now your CPT codes are going to be your 96413 for the first hour and then the 96415 is actually an add on code and that’s for the remaining 30 minutes. Now you want to make sure that your documentation is going to support 1 hour and 30 minutes and not any less than that or you won’t be able to use that add on code. Okay now your diagnosis, the answer is V58.11 and the cancer code 174.9.

Alicia further explained the rationale during the Oct 2012 Q&A Webinar. You can view the video clip and read the transcript when you become a member of the CCO Club.