The essential element of full reimbursement is proper coding. Without the proper codes, payers will not compensate oncology practices for the drugs and services they provide during the course of patient care. It is important to remember that coding is about more than just the drugs used; coding involves all the aspects of treating a patient—diagnosis codes, drug codes, procedure codes, and even administrative codes. In an interview with the Journal of Multidisciplinary Cancer Care, John F. Aforismo, BSc Pharm, RPh, FASCP, chairman and founder of RJ Health Systems International, discusses on- and off-label use, the role of various staff members, and the upcoming switch to International Classification of Diseases, 10th Revision, Clinical Modification (ICD- 10-CM) codes. His knowledge of the payers’ point of view will help practices make the most of their billing.

Why is it important to code properly?

John Aforismo (JA): It is important for two reasons. One, the most obvious reason, is to ensure that the practice is reimbursed appropriately for goods and services that it provided to the patient. The other reason is because the payers who reimburse the oncology practice use coding information for developing patient-management programs. Payers perform data analysis with the information, so they need accurate and proper coding right down to the ICD-9-CM and administrative code level to make data analysis easier.

What are some of the common mistakes oncology practices make when coding?

JA: They may use the incorrect Healthcare Common Procedure Coding System (HCPCS) code for the drug used or any ancillary drugs in question. They may input the wrong code, either one that aligns to a different drug, or just the wrong code. Or they may input a nonclassified code where there is a code already established. That could hinder or slow the reimbursement to the practice.

A practice may also use the incorrect ICD-9-CM code to identify the type of chemotherapy or the site of cancer. Payers are now looking at these codes more closely. In the past, if a practice used the improper HCPCS code for the drug or the amount of units provided, that just stopped the claim. But now if the ICD-9-CM code is not appropriate, if there isn’t one assigned, or if the administrative code used in conjunction with the HCPCS code is not appropriate, the claim will be flagged for a medical review.

Payers are even looking at the dosage units, those that appear in Column 24G of the Centers for Medicare & Medicaid Services (CMS) 1500 claim form. There are databases that provide the minimum and maximum dosing on a specific product, and, if the dosage input on the claim submitted does not fall within that range, a medical review will be triggered.

How can practices ensure proper coding?At the Hematology/Oncology Pharmacy Association annual meeting, one of the speakers said that in some practices, pharmacists in the billing department make sure that drugs are coded properly.

JA: Having a pharmacist in the billing department helps ensure use of the proper National Drug Code (NDC) number and HCPCS code. I’m a pharmacist as well, so I’m not slighting pharmacy at all, but pharmacists probably do not have the right background to look at the ICD-9-CM or administrative codes that also go on a claim form. A nonclinical nurse can help with these aspects. Another method is to use a software product that provides some of this information. A few of these are available.

How can one learn about coding? Is it through on-the-job training or are there courses/special training available?

JA: It is my understanding that there are coding classes that a nurse, or a pharmacist, or someone who’s in charge of billing can take to learn the proper codes for each drug and procedure. BC Advantage in Las Vegas, Nevada, and MedLearn in St. Paul, Minnesota, offer classes. These are companies that hold seminars, either live or via the web, on appropriate coding in oncology as well as other areas of medicine.

How does off-label use of cancer drugs affect coding? How are those drugs coded?

JA: Probably 99% of the payers could not tell you that you are using an oncology product off-label. There are very few databases that will look at that NDC number and say “oh yes, it is US Food and Drug Administration– approved or it is compendia-approved or compendia-listed.”

More important, payers review claims as they arrive. They have started to build fail-safes, which means that when a claim comes in, they will review it retrospectively and inform the provider that an oncolytic was used for an unapproved or an off-label use. Then, the payer will ask for two peer-reviewed studies to back up that use.

Another way that payers strive to ensure that uses are appropriate is what we call “prior authorization” on drugs. Even in oncology, there will be payers that will not pay for specific drugs until the provider advises them why he or she wants to use the drug for a patient. Then the payer will say “here are my criteria to use this drug.” The physician’s office will have to supply that data ahead of time. Once it’s approved, the patient can receive that drug for the approved period of time.

Recently, CMS eliminated consultation codes. Have there been other changes in coding that will affect oncology practice?

JA: I think the main issue that will affect oncology practices in the future is that payers will be asking for appropriate ICD-9-CM codes and appropriate administrative codes that go with a particular drug. They are going to use these data as a method of understanding what the patient was receiving and to build guidelines to treat the patient. Basically, by requiring all this information, the payers are going to be doing some things they never did before—that is, managing patients.

I don’t know of any other recent changes in coding. But, more important, CMS and others are requiring administrative codes. In the future, they also will be requiring various laboratory codes to get a claim reimbursed.

ICD-10-CM is coming soon. Will there be major changes? How can practices prepare for that?

JA: The ICD-10-CM codes are amore definitive method of coding. CMS offers a crosswalk from ICD-9-CM codes to the various ICD-10-CM codes. The best way that a practice can prepare is to keep track of what CMS is doing. Also, I believe there is a database on the CMS website. Practices that focus on a specific cancer or cancers should start studying those code conversions from ICD-9-CM to ICD-10-CM. 2013 (the year the new codes go into affect) isn’t that far away.

Oncology practices should be familiarizing themselves with the oncology codes. How did they break down, for example, breast cancer? As I remember, there may be five or six ICD-9-CM codes for breast cancer now, but with the ICD-10-CM codes, I think there are almost 20. That makes it a more finite coding system. All this is being done basically to track patients.

It sounds like it requires a specialized staff member to keep up-to-date on all the latest coding changes.

JA: I couldn’t agree more. Oncology practices need to have a department with someone who learns not only the proper coding for a CMS 1500 claim form but also the rules and requirements of the various payers that the oncology practice has contracted with. There are nuances within them all.

Are there any other recent developments that will affect payment by private payers?

JA: Today, each oncology practice needs to work with its payers very closely when it comes to contract negotiations and explain how it provides patient care. Don’t always be overly concerned about the cost of the drugs the practice is dispensing and using in the office. Add to the drug costs all the other costs incurred for the services the practice renders to patients. Those costs, sometimes, are neglected. If a practice advises a payer how it takes care of patients, I think the cost structure would be more in line with the complete service provided. Practices tend to concentrate on the drug because it is a tangible item for which the practice needs to get appropriate reimbursement. This is true and fair, but the practice also needs to get appropriate reimbursement on the services rendered to the patients. Even if it’s just an intramuscular injection or having intravenous therapy, a nurse has to spend time with the patient. All these services need to be broken down and explained to the payer, because an understanding of these steps could affect how the practice gets reimbursed by the payer. The more the payer knows, the better it is for a practice to expand its payment rates.

Will there be any aspect of the healthcare reform act that will affect coding in the oncology office?

JA: I think there are aspects of the bill that are going to affect coding in every doctor’s office. The pressure is going to be on for them to see more patients and do more with less staff, but more important, I think coding for oncology care will be more closely scrutinized as more and more patients are seen in oncology offices. So practices will need to be very well versed on the rules. And a point I can’t stress enough is that oncology practices should have, must have, staff who can properly bill according to the rules set down by the various contracts that the office has with its various payers.