Gastroenterology Coding Alert

Photodynamic therapy (PDT) used in conjunction with the drug Photofrin (porfimer sodium) is a non-surgical treatment option for esophageal cancer that is gaining increased acceptance among gastroenterologists and is reimbursable by Medicare. Because this is a multiple-stage treatment process, there are several services provided by gastroenterologists that should be coded and reported for reimbursement.

In the first stage of PDT, the patient receives an intravenous injection of Photofrin. The administration of this drug can be performed by a variety of healthcare providers in a variety of settings, according to Bergein F. Overholt, MD, FACP, MACG, a gastroenterologist in Knoxville, Tenn., and past president of the American Society for Gastrointestinal Endoscopy. Gastroenterologists, nurses or an outside service can administer the drug in an office/outpatient or home setting.

Approximately 48 hours after the drug has been administered, the gastroenterologist performs an upper gastrointestinal endoscopy where the scope is used to pass laser light through the patients throat and into the esophagus. The laser light illuminates the cancerous cells for a period of eight to 12.5 minutes per treated segment, activating the Photofrin and producing a toxic agent that kills the cancerous cells.

Report All Services Provided

The following services and drugs provided during PDT should be reimbursable by both Medicare and commercial insurance companies:

1. The Administration of Photofrin. A gastroenterologist can report the intravenous injection of Photofrin if he or she does the administration or supervises the administration by a nurse. According to the local medical review policy of New Jersey (one of the few states that has a PDT policy), gastroenterologists should [u]tilize the appropriate intravenous chemotherapy code to report the administration of Photofrin.

Codes 90784 (therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous), 96408 (chemotherapy administration, intravenous; push technique), and 96410-96414 (chemotherapy administration, intravenous; infusion technique, various time intervals) are among those cited by Overholt as being appropriate to use depending on the specific situation.

2. Photofrin. If the administration of the drug is performed in an office/outpatient setting, the gastroenterologist also should bill for the Photofrin using code J9600 (porfimer sodium, 75 mg).

3. The Upper Gastrointestinal Endoscopy. Code 43228 (esophagoscopy, rigid or flexible; with ablation of tumor[s], polyp[s], or other lesions[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) is the code most frequently used to report the endoscopy performed during the treatment. New Jerseys local policy also states that 43258 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) can be used when appropriate.

4. The Illumination of the Patient With the Laser Light. Codes 96570-96571 (photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s] [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]), which went into effect on Jan. 1, 2000, are used to report the illumination of the cancerous cells in the patient.

CPT specifically states that these codes 96570-96571 must used in conjunction with code 43228 or 31641 (bronchoscopy, [rigid or flexible]; with destruction of tumor or relief of stenosis by any method other than excision [e.g., laser]), which is not a gastrointestinal procedure. Code 96570 is used to report the first 30 minutes of illumination, and code 96571 is used to report each additional 15 minutes of illumination.

Because these are add-on codes, they dont require the use of a modifier, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.

A follow-up endoscopy is performed a few days after the illumination to determine the patients response to the treatment and is separately reimbursable, notes Overholt. There also may be pretreatment endoscopies done to determine the exact location of the cancerous cells, says Stout, who adds that these pretreatment endoscopies also are separately reimbursable.

Current Indication Is for Obstructing Cancer Only

The current indication for Photofrin is that it can be used with cases of esophageal cancer where there is a complete or partial obstruction of the esophagus. According to the local policy of New Jersey, Medicare will reimburse only when PDT is used for the palliative treatment of patients with partial or complete obstructing esophageal cancer who, in the opinion of their physician, cannot satisfactorily be treated with ND: YAG laser therapy.

Overholt also has used PDT during experimental trials to treat patients with Barretts esophagus, a condition where cellular changes that are often abnormal occur in the lining of the esophagus. Once the federal Food and Drug Administration (FDA) completes the process of approving Photofrin for the treatment of Barretts esophagus, he believes that Medicare also will reimburse when PDT is used to treat that condition, which would be indicated by ICD-9 code 230.1 (malignant neoplasm that has not invaded tissue beyond the epithelium of the esophagus).

Educating Payers May Be Key to Reimbursement

Most carriers do not have a medical policy for this treatment yet, which means that gastroenterologists who want to use PDT will have to contact their local Medicare carrier to get specific coding and coverage requirements.

Just because a local Medicare payer doesnt have a local medical review policy out on a procedure, doesnt mean you wont get reimbursed for it, explains Stout. The gastroenterologist needs to contact the state medical director for their billing guidelines.

Commercial insurance companies may need to be educated on PDT before they will reimburse for the treatment. Doctors need to take the CPT manual and the Medicare advisory newsletter and approach each insurance company that he or she bills, claims Overholt. It will be a one-on-one effort for the next year. But since Medicare is reimbursing for the treatment, its only a matter of time before all the commercial payers pick it up.