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 [...]