Gastroenterology Coding Alert

Bill all three or get a denial: supply, injection, and illumination.

Coding for photodynamic therapy (PDT) involves three key components, which means you should look into multiple CPT® codes to describe your claim appropriately. But this could jeopardize your claims for these procedures if you're not careful of PDT's time increments and restrictive coverage guidelines.

Check out these tips so as not to lose your way into the complexity of PDT multiple coding.

Claim Drug Supply With J9600

Usually, gastroenterologists use PDT as a palliative treatment for esophageal cancer patients who experience difficulty in swallowing caused by the tumor. Physicians also perform PDT as non-surgical treatment for Barrett's Esophagus with high grade dysplasia complications (although still considered experimental by most carriers).

What goes on during PDT: Patients receive an injection of photoactive drug (porfimer sodium), which is absorbed in the tissues, including cancerous or precancerous cells. While this drug disappears from most healthy tissue, it remains in cancer cells and certain other organs. This way, the physician can later target cancerous cells and destroy them with a laser light delivered by a fiber optic endoscope. Patients get sedation during this procedure.

You would report the drug supply with J9600 (Injection, porfimer sodium, 75 mg) only when your gastroenterologist performs PDT in an office/outpatient setting. Make sure you support J9600 with a diagnosis that your carrier accepts as medically necessary. These conditions may include:

• 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.

Remember The 3-Component Rule

Don't forget to report the administration code only when the physician performs the administration or when provided by a nurse under the physician's supervision. The three components that you should consider include:

• the length of time the physician spends on the injection;
• whether the physician performs the PDT on an inpatient or outpatient; and
• whether a doctor is present or not.

The photoactive drug (usually the brand Photofrin), is administered as a single, slow intravenous injection over three to five minutes. With this limitation, the most commonly used CPT®s to report Photofrin administration are:

• 96374 -- 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 infusion technique... (various time intervals).

Extra: You must also regard the type of E/M service for the office visit, in which caseyou would report the appropriate E/M code.

Call On 43228 For Endoscopic Cancer Tissue Destruction

Since the administration of photoactive drug does not happen in the same date as the PDT procedure, you should report a separate code for when the doctor destroys the cancerous tissues with a laser light endoscope at a later time. In such cases, you can bill for an endoscopy. Because the procedure's goal is directed at an esophageal abnormality, you would likely 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).

Option: If the doctor also examines the stomach and duodenum during the esophageal PDT treatment, you would code 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).

In addition to your endoscopy code, you should include a code to describe the light used during PDT. You may choose from:

• 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 gastrointestinal tract); for the first 30 minutes of light treatment; and
• 96571 -- ... each additional 15 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract). Confused yet? Here's an example to help clarify:

Scenario: A 58-year-old male with a history of chronic esophageal reflux and Barrett's esophagus is recently found to have an area of high grade dysplasia on his surveillance endoscopy. After discussion of various treatment options the patient decides to have PDT treatment to ablate the area of high grade dysplasia as well as the other areas of Barrett's mucosa. On a follow-up office visit the provider evaluates the patient for some post procedure abdominal symptoms, and presents him with literature about the risks of Photofrin and PDT.

At the same visit the patient receives a slow intravenous injection of Photofrin 150 mg (2 mg/kg). Two days following the Photofrin injection, the patient returns for upper endoscopy. The provider evaluates the stomach and duodenum for any abnormality, and turns her attention to the esophageal lesion. The provider administers a laser light dose of 130 J/ to the affected area over 30 minutes.

Code it: First you should code the office visit and Photofrin injection, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel. You would report:

• 99214 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.
• 96409 -- Chemotherapy administration; intravenous, push technique, single or initial substance/drug
• J9600 (2 units) -- Injection, porfimer sodium, 75 mg.

For the procedure you should use:

• 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
• 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 gastrointestinal tract); for the first 30 minutes of light treatment.