Oncology & Hematology Coding Alert

Advance to 81539 in prostate screening, and add two new HCPCS S-codes.

Prepare to welcome reforms that are likely to impact your oncology and hematology coding in 2017. You have made exhaustive efforts to align to and adopt ICD-10 reforms. Now it’s time to embrace reforms in screening for prostate cancer and HCPCS coding. Here are some essentials for 2017 that you cannot afford to miss.

Forget 0010M, Report 81539 Instead

As of Jan. 1, CPT^® 2017 adds the code 81539 (Oncology [high-grade prostate cancer], biochemical assay of four proteins [Total PSA, Free PSA, Intact PSA, and human kallikrein-2 (hK2)], utilizing plasma or serum, prognostic algorithm reported as a probability score) to the pathology and laboratory services section for multianalyte assays with algorithmic analyses, called MAAAs.

Note the reform: Prior to this addition, CPT^® listed this test in Appendix O as administrative code0010M. Now there is an independent code, 81539, assigned for the prostate cancer screening.

Note: The code 81539 targets the 4Kscore Test.

Coverage and other considerations: Many payers consider the 81539 test and other biomarker or genetic tests for prostate cancer to be investigational, but that may be changing. When your physician screens for high-grade cancer using 4Kscore, you may be at risk of losing payment for this code. Check with your payer before you submit code 81539.

Make Note of Two New HCPCS S-Codes

In 2017, you have a new HCPCS code S3854 (Gene expression profiling panel for use in the management of breast cancer treatment) for genetic profiling in breast cancer.

Your physician may opt to do gene profiling while managing a patient with breast cancer to prioritize a treatment modality and determine the potential outcomes. Some genetic profiles may have a better prognosis to a particular treatment option. This may help your provider make decisions for chemotherapy and radiotherapy, and predict the likely recurrence of early breast cancer after surgery.

Another new HCPCS code in 2017 is S0311 (Comprehensive management and care coordination for advanced illness, per calendar month). You report code S0311 when, in a patient with terminal cancer, your provider coordinates components of the care and management including management of the patient’s illness, activities of daily living, and psychosocial needs. Your provider will typically coordinate for these services for a calendar month for a patient with cancer who may have a risk of sudden increase in symptoms or decline of functional status. You will note that these services may be expected to last at least a year or until the patient’s death.

How is S0311 different from 99487 and 99489? For complex chronic care management (CCCM) services for patients with two or more advanced conditions, see99487 (Complex chronic care management services, with the following required elements… 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) –  99489 (…each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month [List separately in addition to code for primary procedure]). The HCPCS codeS0311differs from CCCM services in that the latter services are for patients with more than one advanced illness.

“Remember HCPCS ‘S’ Codes are temporary national codes and are not used for Medicare,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services, LLC (“PERCS”), a division of Pinnacle Healthcare Consulting. Turn to CPT^® codes 99487 and 99489 to report these services.

Read more: For more on HCPCS codes in 2017, you can visit the CMS website on: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.

Add 2 New Codes for Anticoagulant Argatroban

As of Jan. 1, 2017, two new codes are available for argatroban. The first code is appropriate for patients who require the drug for reasons not related to end stage renal disease (ESRD). The second code is for patients who need the drug for ESRD-related reasons.

Here are the codes:

• J0883, Injection, argatroban, 1 mg (for non-ESRD use)
• J0884, Injection, argatroban, 1 mg (for ESRD on dialysis).

Of interest to oncology and hematology coders is the code J0883. This anticoagulant, which you may see referred to by the name Acova^®, helps treat and prevent blood clots in patients with low platelet levels (thrombocytopenia) due to heparin. Patients also may receive argatroban if they have, or are at risk for, heparin-induced thrombocytopenia (HIT).

“Argatroban would more commonly be used in the inpatient setting because it’s specifically used for heparin-induced thrombocytopenia, which is not very common, and thrombosis,” says Ray Cathey, PA, MHS, CMSCS, CHCI, president of Medical Management Dimensions in Stockton, Calif. Physicians may use argatroban while switching patients from heparin to warfarin, Cathey adds. It is given intravenously and has a very short half-life of less than one hour, he says.

In 2016, there was a C code available for this drug, C9121 (Injection, argatroban, per 5 mg). HCPCS 2017 deletes this code.

Remember:  Physician coders do not use C codes. CMS initially created C codes for use on Hospital Outpatient Prospective Payment System (OPPS) claims, but a limited number of other providers such as Critical Access Hospitals (CAHs) and Indian Health Service (IHS) hospitals may use the codes.

Unit tip: If you‘re used to reporting C9121, then be sure to note that there is a big difference in your unit reporting between the old and new codes:

• Old code C9121, 1 unit per 5 mg
• New codes J0883 and J0884, 1 unit per 1 mg.

Editor’s note: For more on changes in 2017, you can read the summary published by CMS at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3674CP.pdf.