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Answer: You should be able to get reimbursement for this procedure from Medicare. However, you must follow guidelines regarding diagnosis coding in order to obtain maximum reimbursement. Coding for PDT is complex because the procedure is a two-stage process requiring the administration of both a drug and a light. No single code encompasses the entire procedure.
In the first stage, the patient receives an intravenous injection of Photofrin. According to the local medical review policy statements of Empire Medicare New Jersey, Photofrin (porfimer sodium) is the only FDA-approved agent that can be used during photodynamic therapy. Between 40 and 50 hours later, the gastroen-terologist performs an upper gastrointestinal endoscopy. The laser light illuminates the cancerous cells, which activates the Photofrin and produces a toxic agent that kills the cancerous cells.
It is important to note that Medicare will only cover PDT in cases of esophageal cancer where there is a complete or partial obstruction of the esophagus, and they cannot be treated with ND: laser therapy. PDT is considered investigational when used for conditions other than esophageal and endobronchial/lung cancer or with agents other than Photofrin.
Several diagnosis codes support medical necessity for the use of code J9600 (Porfimer sodium, 75 mg). These include the 150.x series (Malignant neoplasm of esophagus), the 162.x series (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), and 231.2 (Carcinoma in situ of bronchus and lung).
You need to code all services provided while reporting the PDT procedure:
The administration of Photofrin. The gastroen-terologist can code for the intravenous injection of Photofrin if he does the administration or supervises a nurse. One of the codes appropriate for this is 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous).
Photofrin. In an outpatient setting, a gastroenterologist can code for the supply of the drug using J9600.
The upper gastrointestinal endoscopy. Two codes can be used in billing for the endoscopic procedure depending on the circumstances. Code 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) is most often used. The other code that can be billed 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).
The procedure involving use of a laser light. The PDT codes applicable in this case are add-on codes to be reported in addition to bronchoscopy and endoscopy codes. Code +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes) is used for the first 30 minutes of illumination. Each additional 15 minutes should be billed using +96571 (... each additional 15 minutes). |
