Review Of New CPT Codes Affecting BMT Services

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Review Of New CPT Codes AffectingBMT Services

• Presented by James L. Gajewski, M.D.

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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 interpreta-tion 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.
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Overview

• Background
• Review new codes and CMS issues
• Critical care EM issues
• Future concerns

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Background
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Abbreviations

• CPT Current Procedural Terminology
• RVU Relative Value Units
• HCPCS Healthcare Common Procedure Coding System

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Committees

• CPT Editorial Panel
• RVU-RBRVS Update Committee (RUC)
• Outpatient Practice Expense Practice Expense
  Allocation Committee (PEAC)

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Coalition To Address Coding Deficiencies

• 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

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New Billing Regulations

• One price per CPT code
• per patient bill

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Old Codes Are Inadequate

• Apheresis Apheresis
• Plasma Pheresis
• Cell Processing T- and B-cell Removal 86915
  Cross-reference to 88240 and 88241 for
  cryopreservation and thawing

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• CPT editorial committee has been trying to
  enhance granularity of CPT
• Most patient bills need either HCPCS Level I
  better known as CPT codes
• OR
• HCPCS Level II codes attached to services for
  electronic billing of services

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Review Of New Codes

• Rationale behind request
• Facility related expenses
• Physician professional component
• Documentation necessities

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Apheresis

• 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

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ApheresisRationale

• Different costs of disposables for different
  procedures
• Different types of personnel using procedures
  that are commonly performed on emergent basis
• Different level of physician involvement for
  different procedures

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ApheresisFacility Related Expenses

• All apheresis codes are billed as facility based
• Each procedure has separately priced disposables
• Each code has the appropriate technical component
  to assure appropriate billing
• e.g. time for performing a white blood cell or
  plasma exchange may be greater than a red blood
  cell or platelet exchange

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ApheresisFacility Related Expenses

• For governmental payers, these procedures can
  only be billed from hospital based inpatient or
  outpatient facilities
• Project for future is PEAC survey for these
  services so that free standing facilities can
  bill governmental payers

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ApheresisPhysician Professional Component

• Physician work effort surveys were done but RUC
  did not approve of the surveys
• Each apheresis procedure has an RVU of 1.74
• The RVU for 36516 may be decreased to 1.22 in 2004

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ApheresisProfessional 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.

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ApheresisProfessional Billing Criteria

• Evaluation of patients for apheresis is billable
  separately as long as it is done on a different
  day. This is billed on consult HP.
• Post-procedure follow-up is also billable
  separately as long as it is done on a different
  day, following EM service.
• 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.

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Billing for apheresis services would be easier if
apheresis was recognized as a unique specialty!
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Donor Search and Transplant Product Acquisition

• 38204 Management of recipient hematopoietic
  progenitor cell donor search and cell acquisition

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Donor Search and Transplant Product Acquisition
38204Physician Professional Component

• 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.

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Donor Search and Transplant Product Acquisition
38204Facility Related Expenses

• This donor search CPT code may not be used for
  NMDP/Cord Blood Registry donor services on
  product acquisition.
• On patient bills, these services should either
  have no CPT attached or a generic CPT code such
  as 38999.
• Future task is to create HCPCS Level II codes for
  these services.

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Donor Search and Transplant Product Acquisition
38204Facility Related Expenses

• The donor search code will usually be billed
  once. This may be billed for successful and
  unsuccessful searches.
• 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.
• If a DLI or boost from the same donor is used,
  then this code may not be billed twice.

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Donor Search and Transplant Product Acquisition
38204

• Medicare chose not to recognize this code.
  Medicare felt the service should be valued under
  infusion CPT 38240.
• Appeal is underway.

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Stem Cell Collection

• 38205 Blood derived hematopoietic progenitor cell
  harvest for transplantation allogeneic
• 38206 Blood derived hematopoietic progenitor cell
  harvest for transplantation autologous

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Stem Cell Collection 38205 38206 Rationale

• The old codes were split due to expenses for
  donor evaluation

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Stem Cell Collection 38205 38206Facility
Related Expenses

• Both codes cover the collection services for one
  days collection.
• Multiple days services require multiple uses of
  this code.

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Stem Cell Collection 38205 38206Facility
Related Expenses

• For governmental payers, i.e. Medicare or
  Medicaid, these services are facility based.
• They can only be billed from hospital based
  inpatient or outpatient collection facilities.
  This does not apply to non-governmental payers.
• 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

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Stem Cell Collection 38205 38206Suggested
Facility Related Expenses

• The pricing of the service may include
• Nurse/technician time, machine disposables,
  machine depreciation, space utilized and all
  costs associated with meeting regulatory
  requirements.

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Stem Cell Collection 38205 38206Physician
Professional Component

• 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.
• This is a per-day physician charge for management
  of collection. For multiple day collections,
  these codes may be be billed on multiple days.

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Allogeneic Stem Cell Collection 38205
Physician Professional Component

• Allogeneic donor assessment for apheresis should
  be new patient not consult HP (there is not
  referring physician).
• Follow-up after care on a different day may use
  follow-up EM codes.

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Autologous Stem Cell Collection 38206
Physician Professional Component

• Autologous pre-stem cell collection may be billed
  as a consult HP 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.
• Autologous post-proceeding assessment is billable
  by EM codes for follow-up as long as by
  different physicians doing routine cancer care.
  This cannot be billed on the day of collection.

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Cell Processing
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Cell Processing Rationale

• Allow granularity for cell processing so that we
  do not utilize the old 86915 for red blood cell
  depletion
• Codes moved to join other BMT related codes in
  CPT manual
• Removed reference to 88240 and 88241 which were
  designed for laboratory diagnostic procedures not
  therapeutic transplant services

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Cell Processing Codes Rationale

• CPT would only give codes to procedural processes
  that are accepted
• T-cell depletion and tumor purging have codes but
  not CD34 selection
• Stem cell expansion still in research and we
  cannot set code for this service

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Cell ProcessingGeneric Facility Pricing Issues

• 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
• Pricing may include amortization of GMP
  laboratory construction cost but must be
  amortized over 10 years
• RVU-RBRVS Committee established temporary RVUs
  for all of these codes, but CMS chose not to
  recognize these rvus

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Cell ProcessingPhysician Work Effort

• Includes
• Review of data important for cell processing
  decisions
• Supervision of technicians performing an
  individual patients cell processing
• Review and interpretation of quality assurance
  procedures for an individual patients 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

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Cell Processing

• 38207 Transplant preparation of hematopoietic
  progenitor cells cryopreservation and storage

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Cell Processing 38207Suggested Facility
Related Expenses

• For cryopreservation and storage of bone marrow
  or peripheral blood progenitor cells.
• Facility fees include tech time, laboratory
  supplies, machinery, 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.

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Cell Processing 38207Physician Professional
Component

• 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?
• CD34, CD3 tests
• Microbiology testing
• Technician supervision
• Review of freezer curves
• Report generation to review adequacy of
  cryopreserved product and the products ability
  to meet specifications

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Cell Processing

• 38208 Transplant preparation of hematopoietic
  progenitor cells thawing of a previously
  cryopreserved progenitor cell harvest

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Cell Processing 38208Suggested 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

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Cell Processing 38208Physician Professional
Component

• 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

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Cell Processing

• 38209 Transplant preparation of
• hematopoietic progenitor cells washing of
• a previously cryopreserved progenitor cell
• harvest

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Cell Processing 38209Rationale and Suggested
Facility Fee Issues

• For 2003, this is only for thawed cells requiring
  a wash to remove DMSO
• Facility fee should include technician time,
  machinery, supplies and machinery depreciation
• Post-wash viability testing
• In 2004, this code will be redesigned for thawing
  without wash and thawing with wash

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Cell Processing 38209Physician Professional
Component

• Technician supervision of process
• Quality assurance of product after wash
• Report generation to review adequacy of product
  and products ability to meet transplant
  specifications

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Cell Processing

• 38210 T-Cell Depletion

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Cell Processing 38210Suggested Facility
Related Expenses

• 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

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Cell Processing 38210Physician Professional
Component

• 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, CD34 count, CD3
  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

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Cell Processing

• 38211 Tumor cell depletion

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Cell Processing 38211Suggested Facility
Related Expenses

• 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

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Cell Processing 38211Physician Professional
Component

• 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

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Cell Processing

• 38212 Red blood cell removal

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Cell Processing 38212Suggested Facility
Related Expenses

• For a fresh allogeneic harvest removal of RBCs
  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

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Cell Processing 38212Physician Professional
Component

• Review of ABO typing prior to harvest
• Supervision of the process
• Review of quality assurance testing
• Report preparation that product meets or does not
  meet specifications

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Cell Processing

• 38213 Platelet depletion

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Cell Processing 38213Rationale

• For peripheral blood progenitor cell harvest with
  a platelet soft spin
• No RVUs are assigned to this code because no
  physician assessment is done for quality of
  platelet addback given to any donor with low
  platelet counts

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Cell Processing

• 38214 Plasma/volume depletion

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Cell Processing 38214Suggested Facility
Related Expenses

• For a fresh bone marrow harvest and for plasma
  removal
• Facility fees may include technician time,
  supplies, and machinery
• For viability testing after plasma removal
• For 2004, will include flow cytometry testing for
  quality assurance of product

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Cell Processing 38214Physician Professional
Component

• Review of donor/recipient size and ABO blood
  types
• Quality assurance of product
• Supervision of cell processing
• Report generation of product meets or does not
  meet specifications

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Cell Processing

• 38215 Cell concentration of plasma, mononuclear,
  or buffy coat layer

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Cell Processing 38215Rationale

• For mononuclear cell preparation for major/minor
  ABO incompatibility on a fresh bone marrow
  harvest or for further cell processing procedures
• 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

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Cell Processing 38215Physician Professional
Component

• Review of donor/recipient ABO incompatibility
• Supervision of cell processing
• Quality assurance testing
• Report preparation

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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.
• For boost of progenitor cells to treat
  pancytopenia still use 38240, the allogeneic
  transplant infusion code.

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CMS Issues
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The Unprocessed Stem Cells

• CPT editorial board refused our request for a
  code for generic quality assurance testing
• Only option is for those patients to continue to
  bill those services under 38240, 38241, and 38242

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CMS Issues

• CMS did not approve these cell processing
  codes-38207-38215 and the code for unrelated
  donor search and organ acquisition and 38204s
• 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 G-code
  section of HCPCS Level II and will pay for
  cryopreservation and storage at rate for 88240
  and 88241

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CMS Issues

• With the new codes we probably are better off
  with the non-governmental payers
• With CMS, we are no worse off
• Work on these codes brought increased scrutiny to
  all apheresis and BMT related cost
• These codes were presented as facility based. To
  do practice expensing would require a survey of
  how may pipettes, 4x4s, we all use for every
  procedure

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Critical Care EM Issues
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Critical Care

• Critical care can billed for service rendered for
  patient not in MICU
• Advantage of critical care for EM is that it is
  a time based code.
• Critical care pays more RVUs than most complex
  inpatient EM code (4 vs. 1.51, respectively)

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Critical Care

• Critical care is direct delivery by a physician
  of medical care for a critically ill or
  critically injured patient.
• 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 patients condition.
• CPT 2003, Professional Edition

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Critical Care

• 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 patients
  condition.
• CPT 2003, Professional Edition

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Future Concerns
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Future Concerns

• No one is totally satisfied with the results
• Billing these new codes will require more time
  and effort
• Billing is moving to electronic transmittal of
  data. Each item in bill needs either a CPT code
  or HSPCS level II code
• 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.

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Future Concerns

• The January 26, 2003, edition of the New York
  Times 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.

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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