Oncology & Hematology Coding Alert

To ensure complete reimbursement for stem cell treatments, oncology coders should familiarize themselves with the various steps of stem cell harvesting, storage, and transplantation to distinguish between narrowly defined coding options. They can benefit from knowing the roles that other specialists, such as pathologists and hematologists, play in the process.

Myrlena Lee, patient account supervisor for transplant programs at St. Luke's Hospital in Kansas City, Mo., says the physicians and nurse practitioners on the team should be advised how to work with coders because "you can code and bill all you want, but if you're not documenting and getting prior authorizations up front, it's not going to do any good."

Most oncology clinics choose peripheral stem cell transplants over bone marrow transplants, says Beth Harvey, RN, transplant coordinator for the Kansas City Blood and Marrow Transplant Program in Kansas City, Mo. Peripheral, or blood-derived, transplantation is more common with autologous procedures in which a patient receives his or her own stem cells; however, the oncologist may also collect by bone marrow if the peripheral blood collection is not adequate.

"We specialize in autologous peripheral stem cell transplantation because of the ease of collection, faster recovery and long-term disease benefits," says Dipnarine Maharaj, MD, director of the Bone Marrow Stem Cell Transplant Institute at Bethesda in Boynton Beach, Fla., and a fellow of the Royal College of Pathologists of the United Kingdom.

"The patient's oncologist and transplant physician (often a hematologist) will coordinate care carefully while the patient receives chemotherapy," Maharaj says. "The patient typically has an intravenous catheter placed codes 36488-36533, depending on circumstances such as which vein is used and the patient's age to facilitate the frequent blood analyses and treatment procedures that will be taking place."

In some cases, chemotherapy is done for mobilization of the stem cells along with administration of a growth factor, while other mobilizations are done with growth factors alone, Harvey says. Often patients will receive "salvage" chemotherapy in an effort to put them in a minimal disease state prior to mobilization and transplant. Harvey says the typical regimen for mobilization at her clinic is Cytoxan (J9091-J9095) for one day, then administration of a daily growth factor until the cells are collected.

Before stem cell collection, the patient will receive stem cell growth-stimulating factors, through either the catheter (if one is present); an IV push, 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous); or subcutaneous injection, 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).

It is correct to code separately the administration of the growth factors with 90784 or 90782 depending on the administration route. Many Medicare carriers, however, define this process as "stem cell infusion" and state that 38999 (Unlisted procedure, hemic or lymphatic system) should be submitted with appropriate documentation. As with all coding issues, individual payer policy will dictate correct coding and claim submission.

Cytapheresis is the process of collecting blood, separating the stem cells by centrifugation or filtration, and immediately returning the remaining cells to the patient. The procedure may be done in an in- or outpatient setting. "We perform outpatient services, and on average, the patient will come in for three apheresis sessions to collect sufficient stem cells for transplantation," Maharaj says.

Each stem cell cytapheresis session is reported using 38231 (Blood-derived peripheral stem cell harvesting for transplantation, per collection). Be careful not to confuse this with 36520 (Therapeutic apheresis; plasma and/or cell exchange), Lee says.

In addition to coding 38240 (Bone marrow or blood-derived peripheral stem cell transplantation; allogenic) (for infusion, not processing), coders should also include 86915 (Bone marrow or peripheral stem cell harvest, modification or treatment to eliminate cell type[s], [e.g., T-cells, metastatic carcinoma]) to address further modification, treatment and processing of bone marrow specimens.

Following each cytapheresis, stem cells are cryopre-served until time for transplantation, Maharaj says.

A practice or facility that performs bone marrow collection and transplantation can also code the cryopreservation and storage of peripheral blood stem cells using 88240 (Cryopreservation, freezing and storage of cells, each cell line). Notes following the code definitions for bone marrow or stem cell transplantation services (38230-38241) direct coders to 88240 for cryopreservation of blood-derived stem cells. For thawing and expansion of blood-derived stem cells for transplantation, use 88241.

When 88240 or 88241 is used, practices may also bill for 86915, 86890 (Autologous blood or component, collection processing and storage; predeposited) and 86985 (Splitting of blood or blood products, each unit). If the office or facility collected the bone marrow and provided services prior to transplantation, they are entitled to reimbursement for those services, including storing the specimen and splitting the blood.

Before transplantation, the preserved stem cells are thawed, tested and prepared for infusion. This may involve coding for a number of services. For example, thawing of frozen blood-derived stem cells is reported with 88241 (Thawing and expansion of frozen cells, each aliquot). Testing for viability, the presence of bacterial contaminants, and genetic matching may also be carried out and should be coded depending on the services provided (e.g., compatibility studies, 86812-86822). Lee says documentation sometimes gets shorted on the transplant day itself "because so much work goes on up front." She recommends following the lead of "centers like ours who develop a form to link the transplant documentation to the whole process."

Typically, the stem cell transplant is carried out with one or more infusions, similar to administering blood platelets. Code 38241 describes an autologous transplant from the patient's own blood or bone marrow. Code 38240 describes an allogenic transplant of bone marrow or blood-derived stem cells.

Additional anti-graft-rejection drugs may be administered for allogenic transplants and may be reported with 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous), or other appropriate drug-administration code (report the appropriate HCPCS Level II code for the drug).