Oncology & Hematology Coding Alert

Question: How should I code stem cell transplants involving donor leukocyte infusion (DLI)? Would these be coded as 90780 and 90781, or 36430?

Michigan Subscriber

Answer: Stem cell transplantation (38240-38241) is a process where stem cells are harvested from the patient or a donor for intravenous infusion. These cells may be obtained from bone marrow or peripheral blood.
 
The stem cell transplant can be used to effect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy and/or radiotherapy used to treat certain malignant conditions. Allogeneic (healthy donor) stem cell transplant may also be used to restore function in patients with an inherited or acquired deficiency or defect.
 
It is difficult to determine from the limited information provided whether the coding concern centers on administering the stem cells to the patient or stimulating stem cell production prior to harvest.
 
For patients with a rapidly progressing disease who  receive their own stem cells (autologous transfusion), the administration of a recombinant growth factor or a combination of hematopoietic growth factors will mobilize the peripheral stem cells. This ensures that there is a sufficient number of cells to be harvested, and it limits the number of times patient blood must be collected to obtain a complete sample.
 
According to CPT Assistant, April 1996, it is correct to code separately the administration of the growth factors with 90784 (therapeutic, prophylactic or diagnostic injection; intravenous) or 90782 (therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular) depending on the administration route.
 
Many Medicare carriers, however, define this process as "stem cell infusion" and state that 38999 (unlisted procedure, hemic or lymphatic system) should be submitted with appropriate documentation. As with all coding issues, individual payer policy will dictate correct coding and claim submission.
 
Once the stem cells have been harvested and processed, they can be infused into the patient. The bone marrow and peripheral blood stem cells are generally infused using an IV push technique, similar to the administration of blood platelets.
 
To code the administration of stem cells, use 38240 (bone marrow or blood-derived peripheral stem cell transplantation; allogeneic) or 38241 (bone marrow or blood-derived peripheral stem cell transplantation; autologous). A physician may administer more than one stem cell transplant, depending on individual patient requirements and response to treatment.
 
When allogeneic stem cells are used, an additional drug may be required to assist with the prevention of graft rejection, which is called graft-versus-host disease, 996.85.
 
Generally, the administration of an anti-rejection agent is assigned 90784 (therapeutic, prophylactic or diagnostic injection; intravenous). A HCPCS code for the drug may be billed in addition to the administration, as provided for by local payer guidelines.
 
Reader Questions were answered by Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga.; and Lillie McAlister, CPC, president of Double-Diamond Enterprises, a coding and billing consulting firm in Conroe, Texas.