Gastroenterology Coding Alert

When your gastroenterologist uses photodynamic therapy (PDT), you've got three key components to code -- and three potential avenues of reimbursement. Our experts show you how to submit stellar claims every time.

- That reimbursement potential comes with a price, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the Hospital of the University of Pennsylvania in Philadelphia.

- "The multiple codes involved in reporting PDT, as well as restrictive coverage guidelines, can make it difficult to code," she says. "Also, time increments lend to the intricacy of coding for this service."

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What it is: PDT is a two-step treatment used to treat esophageal cancer and lung cancer (it is also gaining acceptance as a viable treatment for Barrett's esophagus). In the first PDT step, the gastroenterologist intravenously administers porfimer sodium (brand name Photofrin). This photosensitizing drug works its way through the patient's system and selectively accumulates in cancerous and precancerous areas.
- Two days later, the physician activates the Photofrin by exposing the tissue to light from an endoscope. When the light hits the photosensitized area, a reaction occurs that destroys the targeted tissue. Physicians use PDT as the sole treatment modality for some patients and with chemotherapy or radiation therapy for others.
- Common supporting diagnoses: Here are some common codes that most carriers will accept as medically necessary conditions for using J9600 (Porfimer sodium, 75 mg):

• 150.x -- Malignant neoplasm of esophagus

• 162.x -- Malignant neoplasm of trachea, bronchus, and lung

• 197.0 -- Secondary malignant neoplasm of lung

• 197.8 -- Secondary malignant neoplasm of other digestive organs and spleen

• 230.1 -- Carcinoma in situ of esophagus

• 231.2 -- Carcinoma in situ of bronchus and lung.

PDT is an arduous procedure for a patient, and reporting it can be a frustrating challenge for coders. The difficulty lies in the procedure's length and all the variables present in each claim.

"Time is a critical factor in coding, and physicians often poorly document time," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. "Additionally, the use of PDT for Barrett's mucosa is still considered experimental by most carriers. Appeals are often needed explaining the reason for PDT."

- Here is a closer look at PDT coding guidelines.

You can report Photofrin injections when the physician performs the administration or when provided by a nurse with the physician's supervision. Codes will vary from situation to situation, Pohlig says.

"You'll select the administration code depending on the length of the infusion, on an inpatient or outpatient, with or without a doctor present," Pohlig says, "in addition to whether it's a billable office visit or not."

Since Photofrin should be administered as a single, slow intravenous injection over 3 to 5 minutes, these are the most commonly used codes for reporting Photofrin administration:

• 90774 -- Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

• 96409 -- Chemotherapy administration; intravenous, push technique, single or initial substance/drug

• 96413-96416 -- Chemotherapy administration, intravenous; various time intervals.

Keep in mind: Contractor policy will determine how to report the administration. Some contractors may bundle the administration code into the reimbursement for the drug. You can bill for Photofrin (J9600) with the injection code when your gastroenterologist performs PDT in an office/outpatient setting. Watch your units, because you'll report J9600 for every 75 mg. Key: "Remember that the Photofrin injection will not have the same date of service as the PDT procedure," Weinstein says.

When the doctor uses the endoscope to deliver light that activates the tissue-destroying agent in Photofrin, you can bill for an endoscopy. Because the procedure goal is directed at an esophageal abnormality, you'll most frequently use 43228 (Esophagoscopy, rigid or flexible; with ablation of tumor[s], polyp[s], or other lesion[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

- If the doctor also examines the stomach and duodenum during the esophageal PDT treatment, the alternative code that you can report is 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).

You also have codes relevant to the light used during PDT.

Use +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]) for the first 30 minutes of illumination. For every quarter-hour after that, use +96571 (... each additional 15 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]).-

- Example: If a patient undergoes 45 minutes of PDT, use 96570 for the first 30 minutes and 96571 x 1 for the final 15 minutes. If the patient had received an hour of treatment, you would code the procedure as 96570 and 96571 x 2. Remember: Because the codes are add-on codes, you won't need any modifiers.

- According to Pohlig, many gastroenterology offices are not as thorough as they should be when reporting PDT-specific codes. "If physicians do not include the time associated with light application, they could miss out on the full reimbursement for this service," she says.

- A few days after the therapy is over, the gastroenterologist performs follow-up to measure the patient's post-PDT progress. An endoscopy also often precedes the PDT by days or weeks to determine the cancerous cells' exact location. You can separately bill both of these additional endoscopic procedures, and carriers should reimburse them fully when you properly report them.

Are you sure your PDT claim is complete? Ask yourself these questions before sending out the claim, and reduce the risk of partial payment or denial:

• Have I billed for a pre-PDT endoscopy if one was performed?

• Have I reported the Photofrin administration if the physician gave the injection or supervised it?

• Have I billed for the Photofrin supply if the administration occurred in an office/outpatient setting?

• Have I reported an endoscopy if the gastroenterologist performed one to send light to the tissue-destroying agent in Photofrin?

• Have I reported the time taken for the PDT session, down to the quarter-hour, using 96570 and 96571?

• Have I billed for the patient's follow-up visit after the photodynamic therapy administration?

If you answered "yes" to all of the above questions relevant to your specific claim, your PDT claim is ready for transmission.