Oncology & Hematology Coding Alert

Question: Which administration code would match to Provenge?

Nevada Subscriber

Answer: Individual payers have final say over which administration code to apply to specific therapies. For example, Palmetto GBA has published guidance that for Provenge administration, you should use therapeutic infusion codes, such as 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour).

You may find other payers who allow chemotherapy codes, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for this immunotherapy treatment, so check individual payers to be sure.

Coverage: CMS recently announced its decision to cover Provenge therapy. Specifically, CMS "has determined that the evidence is adequate to conclude that the use of autologous cellular immunotherapy treatment -- sipuleucel-T; PROVENGE® improves health outcomes for Medicare beneficiaries with asymptomatic  or minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer, and thus is reasonable and necessary for that indication." Access to coverage documents, and to public comments when available, starts here: www.cms.gov/medicare-coveragedatabase/indexes/national-and-local-indexes.aspx.

HCPCS: Effective July 1, you have Q2043 (Sipuleucel-T, minimum of 50 million autologous cdCD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion) available to report the supply. The therapy is based on the patient's own cells, so the infusion bags are patient-specific.

The recommended course for Provenge is three doses given two weeks apart. Each dose is 250 mL (bag contains therapeutic substance suspended in 250 mL of Lactated Ringer's Injection, USP) and is given over roughly 60 minutes.

ICD-9: For payment, Palmetto requires a diagnosis of prostate cancer: 185 (Malignant neoplasm of prostate).

Learn additional Palmetto requirements at www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8HUJLL0580?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email.