Oncology & Hematology Coding Alert

Provenge:

Q2043 No Longer Includes Admin -- Claim Your $71

Published on Sun Jan 09, 2011

Don't miss the effective date for this change.

Medicare offered some positive news for practices providing Provenge. The administration is now separately billable.

History: In Transmittal 2254, dated July 8, 2011, CMS announced that Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion) included all related services. The transmittal specifically listed administration as not separately billable.

But a new transmittal changes all that by stating that you may report the administration separately.

What's new: CMS rescinded Transmittal 2254 and replaced it with Transmittal 2239, dated Nov. 2, 2011, announced Roberta Buell, MBA, of onPoint Oncology in her Nov. 8, 2011, e-Reimbursement newsletter. The new transmittal has an effective date of June 30, 2011, and an implementation date of Aug. 8, 2011. You'll find it online at www.cms.gov/transmittals/downloads/R2339CP.pdf.

Part of the revision is new language stating that "Q2043 is all-inclusive and represents all routine costs except for its cost of administration." CMS also tells payers: "Please note the administration of PROVENGE®, can be billed separately."

Code Q2043 still includes the "transportation process of collecting immune cells from a patient during a non-therapeutic leukapheresis procedure, subsequently sending the immune cells to the manufacturing facility, and then transporting the immune cells back to the site of service to be administered to the patient."

Verify Admin Code With Payer

Now that you may report administration separately, you need to determine which code will apply. Check with your payer to be sure.

Although the complexity of the administration may seem to merit a complex administration code, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug), some payers instruct you to report the lower paying 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour).

For example, check out these policies from Wellmark and Noridian Medicare, which both instruct their providers to report 96365:

Fee reality: Medicare's national rate for 96365 is $71.01 in 2011. Code 96413's 2011 rate is $146.44.

Be sure to add the related MLN Matters update, effective June 30, 2011, to your resources: www.cms.gov/MLNMattersArticles/downloads/MM7431.pdf.