Oncology & Hematology Coding Alert

CPT^® 2022 has plenty of additions to keep you on your toes.

As usual, advances in medical science mean plenty of additions to CPT^®, either on a permanent or temporary basis. A significant number of those additions are impacting your coding now, since some took effect on Oct. 1, 2021, though others aren’t set to be in play until Jan. 1, 2022.

Here are many of the codes you need to know to help you prepare for 4th quarter 2021 and beyond.

Know This Breakthrough mRNA Breast Cancer Test

The COVID-19 public health emergency (PHE) brought the whole issue of molecular ribonucleic acid (mRNA) testing into the public spotlight, as advances in the understanding of mRNA enabled Pfizer-BioNTech, Johnson & Johnson-Janssen, and Moderna to get their COVID-19 vaccines to market in record time.

This same understanding promises to “produce a breakthrough in genetic testing for various cancers,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC in Charlotte, North Carolina, which explains the addition of 81523 (Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis) to the CPT^® 2022 code set.

The potential importance of this test, and others like it, cannot be overstated, as by matching patients to treatment based on gene expression information “NCI researchers showed that their approach could accurately predict whether patients had responded to previous treatment with targeted therapy or immunotherapy,” enabling providers to “match … patients to beneficial treatments” more accurately than ever before (Source: www.cancer.gov/news-events/cancer-currents-blog/2020/tumor-rna-cancer-precision-medicine).

Know These New Category III Oncology Ultrasound and Testing Codes

CPT^® has also introduced a new ultrasound code with an add-on to the Category III codes, which are temporary codes used for “emerging technology, services, procedures, and service paradigms.” The codes, 0689T (Quantitative ultrasound tissue characterization (non-elastographic), including interpretation and report; obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure)) with the add-on +0690T (… obtained with diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure)…), are designed to analyze the intensity and structure of tissue composition in the superspinatous (rotator cuff) and the vastus lateralis muscle (anterior compartment of the thigh) for oncology purposes.

Another groundbreaking procedure added to the CPT^® code set is 0694T (3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3-dimensional automatic specimen reorientation, interpretation and report, real-time intraoperative). This approach uses a single computed tomography (CT) or magnetic resonance imaging (MRI) scan to produce a bio-model of the breast using a 3D printer to calculate and visualize volume differences in the breast.

Last for this section, CPT^® has introduced 0686T (Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance) to describe an experimental procedure where high-intensity acoustic pulses are aimed at targeted tissue within the body, causing the tissue to vaporize.

Know These New PLAs for VWD, Oncology

CPT^® 2022 also introduces 30 proprietary laboratory analyses (PLA) diagnostic (confirmatory) testing codes for hematologic or oncologic conditions. Many of them are not new — the AMA approved a number of them for addition to CPT^® on July 1, 2021 — but their additions are effective Oct. 1, 2021.

Among them are five tests offered by diagnostic lab Versiti for the blood-clotting disorder von Willebrand disease (VWD):

• 0279U (Hematology (von Willebrand disease [VWD]), von Willebrand factor (VWF) and collagen III binding by enzyme-linked immunosorbent assays (ELISA), plasma, report of collagen III binding)
• 0280U (Hematology (von Willebrand disease [VWD]), von Willebrand factor (VWF) and collagen IV binding by enzyme-linked immunosorbent assays (ELISA), plasma, report of collagen IV binding)
• 0281U (Hematology (von Willebrand disease [VWD]), von Willebrand propeptide, enzyme-linked immunosorbent assays (ELISA), plasma, diagnostic report of von Willebrand factor (VWF) propeptide antigen level)
• 0283U (von Willebrand factor (VWF), type 2B, platelet-binding evaluation, radioimmunoassay, plasma)
• 0284U (von Willebrand factor (VWF), type 2N, factor VIII and VWF binding evaluation, enzyme-linked immunosorbent assays (ELISA), plasma)

Two other tests — 0261U (Oncology (colorectal cancer), image analysis with artificial intelligence assessment of 4 histologic and immunohistochemical features (CD3 and CD8 within tumor-stroma border and tumor core), tissue, reported as immune response and recurrence-risk score) manufactured under the brand name Immunoscore, and 0262U (Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score), manufactured by Protean BioDiagnostics — are also effective Oct. 1, 2021.

But at least one healthcare management company, eviCore, has said these two tests do not meet all their criteria for technical and clinical validity, clinical utility, or reasonable use “and are not eligible for reimbursement” (Source: www.evicore.com/-/media/files/evicore/clinical-guidelines/highmark_lab-management-guidelines_v102022_eff01012022_pub08272021.pdf). So, you will need to check with your payers about their guidelines for the test, and inform your patients of any possible financial responsibility, before your provider determines whether to order them.

(For the complete list of the PLA test additions to CPT^® 2022, go to www.ama-assn.org/system/files/cpt-pla-codes-long.pdf).