QUEST Integration - Chemotherapy, Home Intravenous

Original Effective Date:

04/01/2007

Current Effective Date:

01/01/2015

Home administration of intravenous chemotherapeutic drugs should be supervised by the patient’s oncologist. The oncologist is responsible for initiating the chemotherapy treatment and for monitoring the patient’s response to the therapy.

Criteria/Guidelines

• Chemotherapy must be ordered by an oncologist.
• The patient must meet the criteria for homebound as described in the QUEST Integration – Glossary.
• Chemotherapy must meet HMSA’s benefit language and policies related to medical necessity.
• Chemotherapy cannot be administered both at an infusion center and at home for the same course of treatment.
• If a patient’s physician has prescribed chemotherapy using a particular drug for which precertification is required, precertification must be obtained prior to services being rendered.

Documentation

The following documentation should appear in the patient’s case file. In addition, this information should be included with precertification requests:

• Physicians orders/prescriptions, including drug regimen(s). Include the name of the drug, dosage, frequency, rate and duration of therapy (start and end dates). If the regimen is to be cyclical, please note how many cycles are being ordered and how frequently the cycles will be done.
• ICD-10-CM diagnosis code(s)
• Clinical information regarding the primary and secondary diagnoses
• Clinical information documenting the patient’s response to therapy and progress. This information may include laboratory, hematology and radiology reports.
• Patient or caregivers informed consent for home IV therapy

Claims Filing Information

Chemotherapy regimens may be administered continuously or as a repeated cycle (e.g., every four, five, or eight weeks). Please use the codes listed below when submitting claims. Billing should be done in seven-day intervals.

Chemotherapy

Notes:

• When billing for additional chemotherapy on the same day, code a second service line with the appropriate per diem code and modifier code SH. Bill each chemotherapeutic agent separately, being sure to note the correct NDC number for each agent.
• Nursing services are covered during the first 28 days of therapy and do not require precertification. Effective January 1, 2006 nursing services may be billed separately and will no longer be considered as included in the per diem for IV therapy.
• If the patient has been in therapy longer than four weeks (days 29+) and a nursing visit is needed, precertification for the visit is required.
• When administering an anti-emetic drug and/or cytoprotective agent as part of a chemotherapy regimen, no additional per diem or administration charge may be billed. Bill for the drug only.

Example

The patient is receiving treatment for malignant neoplasm of the descending colon. The attending physician prescribes 4 g of fluorouracil daily, continuously infused for five days every month (a cyclical regimen).

The provider bills the per diem charge for the chemotherapy on the first service line:

S9329 x 5 units

The drug is billed on the second service line, using HCPCS code J9999 and the NDC number for the drug. The units (column 24G) are calculated as follows:

Fluorouracil is dispensed in a 10 mL vial that is equivalent to half a gram. To obtain the required four grams, the patient would receive eight 10 mL vials of medication or 80 milliliters each day. Over five days a total of 400 milliliters of fluorouracil will have been given.

J9999 NDC: 00004-1977-01 x 400 units

If the patient were to receive an anti-emetic (e.g., Zofran). The anti-emetic would be shown on the next service line following the chemotherapy drug using J3490 and the NDC number of the product.

Revision History