Oncology & Hematology Coding Alert

Be sure to check the effective date for these edits.

October 1, 2011, brings Correct Coding Initiative (CCI) 17.3 for physician coders. Be sure to check for Q2043 and 36xxx changes before you send in your next claim.

Think Twice Before Pairing a Code With Q2043

The latest version of CCI adds 1,380 new edit pairs, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, LLC, in his NCCI 17.3 Update (available at www.frankcohen.com/html/access.html).  

He notes that more than 12 percent of the edits involve Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion). This long list may not be a surprise considering CMS's announcement that Q2043 is essentially a one-stop shop, including:

• Transportation process of collecting immune cells from a patient during a non-therapeutic leukapheresis procedure
• Subsequently sending the immune cells to the manufacturing facility
• Transporting the immune cells back to the site of service to be administered to the patient
• The infusion of the immune cells to the patient.

Most of the edits place Q2043 in the column 1 position. Among those edits, some have a modifier indicator of 1 (you may override the edit under certain circumstances) and some have a modifier indicator of 0 (you may never override the edit). (See "Refresh Your Knowledge of How to Legitimately Override Edits" below for more detail.)

'1' example: CCI now bundles 96372-96375 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug] ...) into Q2043. These edits have a modifier indicator of 1. As a result, if the Q2043 service and 9637x service are distinct, you may use a modifier (such as 59, Distinct procedural service) on the appropriate 9637x code to override the edit.

'0' example: CCI bundles 36512-36516 (Therapeutic apheresis ...) into Q2043. Because these edits have a modifier indicator of 0, you may never override the edits.

Watch for: Code Q2043 doesn't always fall in column 1. In one new edit, CCI places 36522 (Photopheresis, extracorporeal) in column 1 and Q2043 in column 2. The edit has a modifier indicator of 1, so you may override the edit with a modifier when appropriate. To keep your claims compliant, never report 36522 to reflect a portion of the service Q2043 describes.

Extracorporeal photopheresis (36522) is a treatment for patients with cutaneous T-cell lymphoma who haven't responded to standard treatment, according to CPT® Assistant (August 2010). The patient ingests drugs that are activated by light and then is connected to a machine that withdraws blood and separates it into component parts. The blood is returned to the patient after irradiation of the white blood cells and some of the plasma with ultraviolet light, CPT® Assistant explains.

Effective date: CCI 17.3 lists July 1, 2011, as the effective date for these edits. So even if you're submitting claims for services as far back as July 1, you should apply the new edits.

Don't Assume Old 36xxx Edits Still Apply

This version of CCI deletes 835 pairs, notes Cohen. A large number of those eliminate edits that had 36xxx vascular introduction and injection procedures in column 1.

For example: CCI 17.3 deletes the edits bundling 96372-96376 into 36430 (Transfusion, blood or blood components). These edits had a modifier indicator of 1, so you were able to override them with a modifier. Now, you should not need the modifier for payers who apply CCI edits.

Resource: You can download the current edits from www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.