Oncology & Hematology Coding Alert

Stay alert for limited opportunities to report distinct E/M.

When it comes to applying codes correctly, veteran coders know that coding guidelines can be as important as code definitions. Review this Q&A -- and the guidelines in your manual -- to ensure you apply stem cell transplant and lymphocyte infusion codes correctly in 2013.

Background: CPT® 2013 will revise and add to the list of stem cell transplant codes, as explained in "38243 Will Bring a New Option for HPC Boost Starting January 1," in Oncology & Hematology Coding Alert, vol. 14, no. 11.

Effective Jan. 1, 2013, CPT® will delete the crossed out text and add the underlined text shown below:

• Revised: 38240, Bone marrow or blood-derived peripheral stem Hematopoietic progenitor cell transplantation(HPC); allogeneic transplantation per donor
• Revised: 38241, ... autologous transplantation
• New: 38243, ... HPC boost
• Revised: 38242, Bone marrow or blood-derived peripheral stem cell transplantation Allogeneic lymphocyte infusions; allogeneic donor lymphocyte infusions

1. What's the Timeframe for an HPC Boost?

An HPC boost can take place days, months, or years after the original transplant, state CPT® 2013 guidelines for "Transplantation and Post-Transplantation Cellular Infusions." The same holds true for lymphocyte infusions.

An HPC boost is an infusion of HPCs from the original donor. The physician orders the boost to treat a relapse or post-transplant cytopenia (reduction in number of blood cells). You'll report this service using new-for-2013 code 38243 (Hematopoietic progenitor cell [HPC]; HPC boost).

A lymphocyte (type of white blood cell) infusion is ordered to treat relapse, infection, or post-transplant lymphoproliferative syndrome. You should report this service in 2013 using revised code 38242 (Allogeneic lymphocyte infusions).

2. What's Included in 38240-38243?

According to CPT® guidelines, you should not report the following services in conjunction with 38240-38243:

• Physician monitoring of physiologic parameters
• Physician verification of cell processing
• Patient evaluation immediately before, during, and after HPC/lymphocyte infusion
• Physician presence and direct supervision of clinical staff during infusion
• Management of uncomplicated adverse events, such as nausea and urticaria (hives)
• Incidental hydration and fluids used for administration
• Concurrent infusions of medications.

3. Which Services Are Separately Reportable?

CPT® guidelines also provide information on which services you may report in addition to 38240-38243.

You may report E/M codes on the same date as 38240-38243 if that E/M is separately identifiable and supported by the progress note documentation. Guidelines instruct you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to identify the separate visit service performed.

The guidelines also state that "post-transplant infusion management of adverse reactions is reported separately using the appropriate E/M, prolonged service or critical care code(s)." Keep in mind, however, that guidelines instruct you to not separately report treatment of uncomplicated adverse events during the infusion.

Finally, CPT® guidelines for the new code specify that you may separately report hydration and medication administration unrelated to the transplant. Append modifier 59 (Distinct procedural service) to show the service was properly ordered and provided beyond what is normally an inclusive, necessary component of an HPC or lymphocyte service.