Review Of New CPT Codes Affecting BMT Services Presented by: James L. Gajewski, M. D.
Disclaimer: Please note that the opinions expressed in this presentation are those of the presenter and, as such, are intended as guidance only. As always, final interpretation of the requirements of any code, including the acceptability of billing and documentation practices, rests in the domain of the private payer or authorities of the Centers for Medicare and Medicaid Services.
Overview n Background n Review new codes and CMS issues n Critical care E&M issues n Future concerns
Background
Abbreviations n CPT = Current Procedural Terminology n RVU = Relative Value Units n HCPCS = Healthcare Common Procedure Coding System
Committees n CPT Editorial Panel n RVU-RBRVS Update Committee (RUC) n Outpatient Practice Expense – Practice Expense Allocation Committee (PEAC)
Coalition To Address Coding Deficiencies n n Sponsor: American Society of Hematology Co-Sponsors: – American Society for Blood and Marrow Transplantation – American Association of Blood Banks – International Society of Cellular Therapy – The National Marrow Donor Program – American Society of Clinical Oncologists – American Red Cross – Exempt Cancer Centers Committee – Foundation for Cellular Therapies
New Billing Regulations One price per CPT code per patient bill
Old Codes Are Inadequate n Apheresis Plasma Pheresis n Cell Processing T- and B-cell Removal 86915; Cross-reference to 88240 and 88241 for cryopreservation and thawing
n CPT editorial committee has been trying to enhance “granularity” of CPT n Most patient bills need either HCPCS Level I better known as CPT codes OR n HCPCS Level II codes attached to services for electronic billing of services
Review Of New Codes n Rationale behind request n Facility related expenses n Physician professional component n Documentation necessities
Apheresis n Therapeutic apheresis: – 36511 For white blood cells – 36512 For red blood cells – 36513 For platelets – 36514 For plasma pheresis – 36515 With extracorporeal immunoadsorption and plasma reinfusion – 36516 With extracorporeal selective adsorption or selective filtration and plasma reinfusion
Apheresis Rationale n Different costs of disposables for different procedures n Different types of personnel using procedures that are commonly performed on emergent basis n Different level of physician involvement for different procedures
Apheresis Facility Related Expenses All apheresis codes are billed as facility based n Each procedure has separately priced disposables n Each code has the appropriate technical component to assure appropriate billing n – e. g. time for performing a white blood cell or plasma exchange may be greater than a red blood cell or platelet exchange
Apheresis Facility Related Expenses n For governmental payers, these procedures can only be billed from hospital based inpatient or outpatient facilities n Project for future is PEAC survey for these services so that free standing facilities can bill governmental payers
Apheresis Physician Professional Component Physician work effort surveys were done but RUC did not approve of the surveys n Each apheresis procedure has an RVU of 1. 74 n The RVU for 36516 may be decreased to 1. 22 in 2004 n
Apheresis Professional Billing Criteria 1. Procedural professional fee does not require physician to do procedure, but requires physician to examine patient during procedure and demonstrate active supervision of procedure. 2. Physician must be available. Available means within hospital during entire procedure. This does not mean the physician must remain in pheresis unit.
Apheresis Professional Billing Criteria 3. Evaluation of patients for apheresis is billable separately as long as it is done on a different day. This is billed on consult H&P. 4. Post-procedure follow-up is also billable separately as long as it is done on a different day, following E&M service. 5. For inpatients, different physicians from same specialty may bill service on the same day. Hematologists follow acute leukemia on inpatients and different hematologists perform apheresis procedures.
Billing for apheresis services would be easier if apheresis was recognized as a unique specialty!
Donor Search and Transplant Product Acquisition n 38204 Management of recipient hematopoietic progenitor cell donor search and cell acquisition
Donor Search and Transplant Product Acquisition – 38204 Physician Professional Component n For physician supervision of donor search coordinators identifying an unrelated donor and communicating with donor center medical directors and the harvesting physicians. This code is also to be used for cord blood searches. Patient contact is not necessary for this code to be billed.
Donor Search and Transplant Product Acquisition – 38204 Facility Related Expenses n This donor search CPT code may not be used for NMDP/Cord Blood Registry donor services on product acquisition. n On patient bills, these services should either have no CPT attached or a generic CPT code such as 38999. n Future task is to create HCPCS Level II codes for these services.
Donor Search and Transplant Product Acquisition – 38204 Facility Related Expenses n The donor search code will usually be billed once. This may be billed for successful and unsuccessful searches. n If a search goes to BMT, the BMT fails and a new search is done for a new donor, this code may be billed twice. n If a DLI or boost from the same donor is used, then this code may not be billed twice.
Donor Search and Transplant Product Acquisition – 38204 n Medicare chose not to recognize this code. Medicare felt the service should be valued under infusion CPT 38240. n Appeal is underway.
Stem Cell Collection n 38205 Blood derived hematopoietic progenitor cell harvest for transplantation; allogeneic n 38206 Blood derived hematopoietic progenitor cell harvest for transplantation; autologous
Stem Cell Collection – 38205 & 38206 Rationale n The old codes were split due to expenses for donor evaluation
Stem Cell Collection – 38205 & 38206 Facility Related Expenses Both codes cover the collection services for one day’s collection. Multiple day’s services require multiple uses of this code.
Stem Cell Collection – 38205 & 38206 Facility Related Expenses n For governmental payers, i. e. Medicare or Medicaid, these services are facility based. n They can only be billed from hospital based inpatient or outpatient collection facilities. This does not apply to non-governmental payers. n If we try to make these codes not-facility based, the issue is whether nurse time can be attached to practice expense or must be allocated to professional fee. This needs to be better understood before doing a PEAC survey
Stem Cell Collection – 38205 & 38206 Suggested Facility Related Expenses n The pricing of the service may include: Nurse/technician time, machine disposables, machine depreciation, space utilized and all costs associated with meeting regulatory requirements.
Stem Cell Collection – 38205 & 38206 Physician Professional Component n Physicians may bill for this procedure even if not doing the procedure. RVU valuation was for physician supervision of nurse/ technician performing the procedure. To bill, the physician must document exams during procedures and supervision of staff for a particular patient. Physician must remain within hospital for entirety of procedure and be immediately available. The physician does not need to be in the apheresis unit for entirety of procedure. n This is a per-day physician charge for management of collection. For multiple day collections, these codes may be be billed on multiple days.
Allogeneic Stem Cell Collection – 38205 Physician Professional Component n Allogeneic donor assessment for apheresis should be new patient – not consult H&P (there is not referring physician). n Follow-up after care on a different day may use follow-up E&M codes.
Autologous Stem Cell Collection – 38206 Physician Professional Component n Autologous pre-stem cell collection may be billed as a consult H&P if the physician doing apheresis is different from the physician managing the cancer care. This can be a “within specialty” consult; however, this consult cannot be done on the day of collection. Wording of consult is important-or it will be a referral-transfer of care. n Autologous post-proceeding assessment is billable by E&M codes for follow-up as long as by different physicians doing routine cancer care. This cannot be billed on the day of collection.
Cell Processing
Cell Processing Rationale Allow granularity for cell processing so that we do not utilize the old 86915 for red blood cell depletion n Codes moved to join other BMT related codes in CPT manual n Removed reference to 88240 and 88241 which were designed for laboratory diagnostic procedures not therapeutic transplant services n
Cell Processing Codes Rationale n CPT would only give codes to procedural processes that are accepted n T-cell depletion and tumor purging have codes but not CD 34 selection n Stem cell expansion still in research and we cannot set code for this service
Cell Processing Generic Facility Pricing Issues n n These are per day codes Markets sets prices, but in assessing cost to determine institutional pricing consider including: – Technician time, supplies, machine use, machine depreciation, space costs, malpractice risk, quality assurance testing of an individual product, overhead n n Pricing may include amortization of GMP laboratory construction cost but must be amortized over 10 years RVU-RBRVS Committee established temporary RVU’s for all of these codes, but
Cell Processing Physician Work Effort n Includes: – Review of data important for cell processing decisions – Supervision of technicians performing an individual patient’s cell processing – Review and interpretation of quality assurance procedures for an individual patient’s cells being processed, including flow cytometry – Report on product adequacy and ability of cellular product to meet expectations – Time for report preparation and review of cell processing – Malpractice risk – Psychological stress
Cell Processing 38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage
Cell Processing – 38207 Suggested Facility Related Expenses • For cryopreservation and storage of bone marrow or peripheral blood progenitor cells. • Facility fees include tech time, laboratory supplies, machinery depreciation, and space costs. • If mononuclear cell processing was done prior to cryopreservation, it should be billed separately. • Cryopreservation charge should include all quality assurance testing. • After 2004, this code will include billing for all flow cytometry tests used for quality assurance testing.
Cell Processing – 38207 Physician Professional Component n Planning for cryopreservation – How many stem cells or T-cells will be stored to meet needs of transplant? – What are anticipated issues? » Donor-recipient HLA/ABO/infectious disease serology, recipient/donor size disparity – What is RBC contamination of product? – Which quality assurance procedures will be performed? » CD 34, CD 3 tests » Microbiology testing – – – Technician supervision Review of freezer curves Report generation to review adequacy of cryopreserved product and the product’s ability to meet specifications
Cell Processing 38208 Transplant preparation of hematopoietic progenitor cells; thawing of a previously cryopreserved progenitor cell harvest
Cell Processing – 38208 Suggested Facility Related Expenses • For thawing of harvest on the day of infusion • Includes all equipment, equipment depreciation, space costs, and technician time used in thawing process • Post thaw viability testing
Cell Processing – 38208 Physician Professional Component n Includes: – Review of patient/donor data, freezer curves, adequacy of cryopreserved product – Supervision of thawing, quality assurance testing of pre- and post-thaw product i. e. viability testing flow cytometry (obviously this does not hold up thaw) – Need for special procedures for thawing processes i. e. need for wash; concerns for incompatible RBC contamination – Report on product adequacy and ability to meet specifications – Preparation time for a thaw report – After 2004, flow cytometry will not be billed separately
Cell Processing 38209 Transplant preparation of hematopoietic progenitor cells; washing of a previously cryopreserved progenitor cell harvest
Cell Processing – 38209 Rationale and Suggested Facility Fee Issues For 2003, this is only for thawed cells requiring a wash to remove DMSO n Facility fee should include technician time, machinery, supplies and machinery depreciation n Post-wash viability testing n In 2004, this code will be redesigned for thawing without wash and thawing with wash n
Cell Processing – 38209 Physician Professional Component Technician supervision of process n Quality assurance of product after wash n Report generation to review adequacy of product and product’s ability to meet transplant specifications n
Cell Processing 38210 T-Cell Depletion
Cell Processing – 38210 Suggested Facility Related Expenses n n n Facility fees may include machinery, machinery depreciation, technician time, supplies, space costs, and quality assurance testing If cryopreservation is needed, it may be billed separately If mononuclear cell separation not usually done prior, then may be billed separately Tests to evaluate efficacy of T-cell depletion Tests to evaluate viability after T-cell depletion In 2004, will include flow cytometry testing, pre and post
Cell Processing – 38210 Physician Professional Component n n n n Assess donor/recipient suitability for T-cell depletion Assess HLA typing, donor/recipient size disparity Assess quality of product coming to lab for T-cell depletion, cell number, CD 34 count, CD 3 counts Supervision of technician performing processing Assessment of efficacy of T-cell depletion Review and interpretation of quality assurance testing Report preparation on quality of product to meet specifications
Cell Processing 38211 Tumor cell depletion
Cell Processing – 38211 Suggested Facility Related Expenses n n n n For autologous transplantation Facility fees may include machinery, machinery depreciation, technician time, supplies, space costs and quality assurance testing Testing to document efficacy of tumor purging Testing to document post-tumor purging cell viability Cryopreservation is always done and therefore should not be billed separately If mononuclear cell separation is always done, it should be included in pricing; if not, do not include in pricing After 2004, flow cytometry assessment must be included in pricing and cannot be billed separately
Cell Processing – 38211 Physician Professional Component n n n Assessment of need for tumor purging Assessment of quality of product for tumor purging Supervision of technician performing tumor purging Assessment of efficacy of tumor purging QA testing and review Report preparation on quality of product and that product meets specifications requested
Cell Processing 38212 Red blood cell removal
Cell Processing – 38212 Suggested Facility Related Expenses n n n For a fresh allogeneic harvest; removal of RBC’s in preparation for transplant Facility fees may include tech time, supplies, machinery and red cell depletion for a major ABO incompatible bone marrow harvest Testing of efficacy of RBC removal Testing of viability of progenitor cells after RBC removal In 2004, will include price for flow cytometry testing for quality assurance
Cell Processing – 38212 Physician Professional Component Review of ABO typing prior to harvest n Supervision of the process n Review of quality assurance testing n Report preparation that product meets or does not meet specifications n
Cell Processing 38213 Platelet depletion
Cell Processing – 38213 Rationale For peripheral blood progenitor cell harvest with a platelet soft spin n No RVU’s are assigned to this code because no physician assessment is done for quality of platelet addback given to any donor with low platelet counts n
Cell Processing 38214 Plasma/volume depletion
Cell Processing – 38214 Suggested Facility Related Expenses For a fresh bone marrow harvest and for plasma removal n Facility fees may include technician time, supplies, and machinery n For viability testing after plasma removal n For 2004, will include flow cytometry testing for quality assurance of product n
Cell Processing – 38214 Physician Professional Component Review of donor/recipient size and ABO blood types n Quality assurance of product n Supervision of cell processing n Report generation of product meets or does not meet specifications n
Cell Processing 38215 Cell concentration of plasma, mononuclear, or buffy coat layer
Cell Processing – 38215 Rationale For mononuclear cell preparation for major/minor ABO incompatibility on a fresh bone marrow harvest or further cell processing procedures n For occasional mononuclear cell separation for further manipulation, if this is not routinely done for additional procedures then mononuclear cell preparation may be billed separately n
Cell Processing – 38215 Physician Professional Component Review of donor/recipient ABO incompatibility n Supervision of cell processing n Quality assurance testing n Report preparation n
38242 Donor Lymphocyte Infusion This code is to administer a post allogeneic donor lymphocyte infusion to treat relapse of malignancy or infection after allogeneic bmt. n For boost of progenitor cells to treat pancytopenia still use 38240, the allogeneic transplant infusion code. n
CMS Issues
The Unprocessed Stem Cells CPT editorial board refused our request for a code for generic quality assurance testing n Only option is for those patients to continue to bill those services under 38240, 38241, and 38242 n
CMS Issues n n CMS did not approve these cell processing codes-38207 -38215 and the code for unrelated donor search and organ acquisition and 38204 s These codes can be used to bill these services to non-governmental payers CMS has always had difficulty paying for organ acquisition costs CMS moved these codes 38207 to 38215 to Gcode section of HCPCS Level II and will pay for cryopreservation and storage at rate for 88240 and 88241
CMS Issues With the new codes we probably are better off with the non-governmental payers n With CMS, we are no worse off n Work on these codes brought increased scrutiny to all apheresis and BMT related cost n These codes were presented as facility based. To do practice expensing would require a survey of how may pipettes, 4 x 4’s, we all use for every procedure n
Critical Care E&M Issues
Critical Care Critical care can billed for service rendered for patient not in MICU n Advantage of critical care for E&M is that it is a time based code. n Critical care pays more RVU’s than most complex inpatient E&M code (4 vs. 1. 51, respectively) n
Critical Care Critical care is direct delivery by a physician of medical care for a critically ill or critically injured patient. n A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. n CPT 2003, Professional Edition
Critical Care n Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening, deterioration of the patient’s condition. CPT 2003, Professional Edition
Future Concerns
Future Concerns n No one is totally satisfied with the results n Billing these new codes will require more time and effort n Billing is moving to electronic transmittal of data. Each item in bill needs either a CPT code or HSPCS level II code n Billing these codes is important in case rate payments because underlying charges determine how case rate payment is allocated within institutions. Even if bill is paid as case rate, third party payers are to receive itemized bill.
Future Concerns n The January 26, 2003, edition of the New York Time’s indicated we and our hospitals cannot expect to charge as much as we are to pharmaceuticals. We will need these services with legitimate costs adequately to justify current case rates.
ASBMT and the bmt community owes a great debt for the service of Samuel Silver, M. D. , Ph. D. and ASH staff Their ongoing labors for financial issues have not received the national accolades they deserve
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