Oncology & Hematology Coding Alert

Missing even subtle revisions could land your claim in limbo.

As is the annual expectation with the oncology specialty, CPT^®s (“Current Procedural Terminology”) anticipated 2019 oncology code changes focus on radiology and lab codes.

While CPT^® may incorporate some of these changes for the sake of sheer practicality, you will find most changes are the result of the American Medical Association’s (AMA) Relativity Assessment Workgroup (RAW) bundling mandates.

Begin your preparations for 2019 by getting a head start on these crucial anticipated CPT^® changes.

Learn the AMA’s Process for Determining Revisions, Deletions and Additions

Sometimes, it feels like code changes to the CPT^® manual seemingly come at random. However, the AMA actually has a precise formula in place to help make these determinations.

“Each year the AMA’s Relativity Assessment Workgroup evaluates potential mis-valued codes to determine whether two codes are performed together at least 75 percent of the time,” says Amanda Corney, MBA, medical billing operations manager for Medical Resources Management in Rochester, New York. “If two codes are typically performed in conjunction with one another, a single combination code more accurately depicts the services may be created,” Corney explains.

In other words, the AMA identifies code pairs providers perform together more than 75 percent of the time. In these instances, the AMA suggests CPT^® bundle these procedures into one combination code.

Check Out New Breast MRI Codes

Among the new additions for 2019, you’ll find four new MRI codes:

• 77046 (Magnetic resonance imaging, breast, without contrast material; unilateral)
• 77047 (… bilateral)
• 77048 (Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral)
• 77049 (… bilateral).

Example: This means if your oncologist performs an MRI on the left breast without contrast material and includes CAD, then you should report 77048-LT (Left side).

These codes replace the deleted codes:

• 77058 (Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral)
• 77059 (… bilateral).

Break Out These BRCA1 Analysis Options

You can wave bye-bye to 81211-81214 as of January 1 of next year. These codes are among the CPT^® 2019 deletions, but you’ll need to get more specific as to which BRCA test the oncologist orders.

New codes: In their place, you’ll have more specific options:

• 81163 (BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81164 (… full duplication/deletion analysis (ie, detection of large gene rearrangements)
• 81165 (BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81166 (… full duplication/deletion analysis (ie, detection of large gene rearrangements)
• 81167 (BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements).

If your oncologist orders a full duplication/deletion BRCA2 gene analysis test because the patient’s mother had ovarian cancer, you would report 81167.

Revisions: Along the same lines, you’ll have revisions to the following existing BRCA codes (emphasis added):

• 81162 (BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements))
• 81212 (… 185delAG, 5385insC, 6174delT variants)
• 81215 (BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant)
• 81216 (BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis)
• 81217 (…known familial variant)

Check Out These Other Lab Additions/Revisions

New BRCA gene analysis codes aren’t the only lab codes you should add to your coding cache. You’ve also got the following new codes to learn:

• 81233 (BTK (Bruton’s tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F))
• 81236 (EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence)
• 81237 (EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646))
• 81345 (TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region))
• 81518 (Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy)

“All of the new gene analysis codes can be important to the oncologist as they look for certain gene changes in cancer cells. This may provide oncologists information about the patient’s prognosis and assist in determining whether certain types of treatment would be considered and useful in their treatment regimen options” says Kristen Taylor, CHC, CPC, Associate Partner for Pinnacle Enterprise Risk Consulting Services.

Don’t forget U codes: You may recall last year CPT^® 2018 included a new section listing codes for Proprietary Laboratory Analyses (PLA). These are alpha-numeric codes assigned with approval by the AMA CPT^® Editorial Panel for unique lab tests a specific clinical laboratory or test manufacturer produces or provides. The lab or manufacturer may apply for a code, with new codes released quarterly. PLAs may be Advanced Diagnostic Laboratory Tests (ADLTs) or Clinical Diagnostic Laboratory Tests (CDLTs) as defined under the Protecting Access to Medicare Act of 2014 (PAMA). Many of the tests may be for multianalyte assays with algorithmic analyses (MAAAs) or genomic sequencing procedures (GSPs), but the PLA codes may include other types of medical laboratory tests.

You’ll need to add the following “U” codes to your coding cache:

• 0067U (Oncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [MMP-1], carcinoembryonic antigen-related cell adhesion molecule 6 [CEACAM6], hyaluronoglucosaminidase [HYAL1], highly expressed in cancer protein [HEC1]), formalin-fixed paraffin-embedded precancerous breast tissue, algorithm reported as carcinoma risk score)
• 0069U (Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score)

Revisions: Do not overlook the following revisions (emphasis added):

• 81287 (MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis)
• 81327 (SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis).