Oncology & Hematology Coding Alert

There are two main reasons for breaking out these codes: The procedures named are expensive, and they require a lot of work. Essentially, Silver says, CPT is trying to describe in finer granularity what bone-marrow-transplant physicians and technicians do because CPT anticipates more billing and tracking issues in the future.

"We will probably be seeing more stand-alone, nonfacility stem cell laboratories who will want to bill for all the different steps they take rather than lumping them into a single process," Silver predicts.

Additionally, these cellular product codes require a tremendous amount of physician oversight because if the doctor does something wrong, the patient at the other end may die. For example, a donor in South Africa donates his stem cells to a patient in Houston. The patient in Houston has received a lethal dose of chemotherapy and awaits his transplant. If anything goes wrong in the lab over the next 12 hours, the patient may die. "It's not like you can take another bag of blood off the shelf," Silver warns.

Until this year, physicians weren't receiving any compensation for the enormous risk inherent in these procedures. Now there is a laboratory-based code with a physician work component, which is distinctly unusual, Silver says.

The detailed spectrum of new 2003 codes "allows us to itemize the work done in units that make sense," says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant in New Orleans.

Codes used for preparation of the stem cells include:

A new code for the infusion of donor lymphocytes 38242, Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions covers a potentially risky procedure. Because donor infusions can cause allergic reactions in patients, Silver says, the AMA's RVU Update Committee (RUC) struggled to assign an appropriate work value to this code.

The RUC also hopes this code will stave off inappropriate denials from insurance companies that treat the procedure like a second transplant, since patients receive these donor lymphocyte infusions after the initial bone marrow transplant. With the creation of separate stem cell and lymphocyte infusion codes, "we've defined a procedure that's commonly done after a bone marrow transplant and a code that will appropriately describe that procedure," Silver says.

Apheresis is the process of removing a specific component from blood and returning the remaining components to the donor. Six new apheresis codes also impact bone marrow and stem cell transplants in 2003:

All the apheresis codes are now assigned the same RVUs. "They don't have any practice expense because they're considered to be a facility procedure," Silver says. "CPT is primarily interested in tracking these procedures during the upcoming year" because the last two codes (36515 and 36516) require extremely pricey, disposable units."

One of the most important codes in the entire CPT 2003 may be 38204, Management of recipient hematopoietic progenitor cell donor search and cell acquisition.

This code represents a whole new way of thinking about physician work, Silver says. Finding an unrelated donor requires a lot of work by the physician, yet it doesn't occur face-to-face with the patient, as do most procedures. If CMS comes through, Silver says, transplant physicians will be allowed to bill once per transplant for unrelated bone marrow donor management.

Even if you don't use this code every day, the introduction of management codes will become increasingly important when gene therapies enter into the everyday clinical world, Silver believes. There is "all kinds of stuff coming down the pike that will constitute individualized, specific cellular therapy for patients." Oncology experts agree that assigning a reimbursable value to these "cognitive services" may be the thin end of the wedge for the future of oncology coding.

Adding these codes allows for appropriate billing of services rendered rather than the catchall codes for bone marrow (or peripheral blood stem cell) harvesting and bone marrow (or PBSC) transplantation we had before, Hickey says.

However, in a recent program memorandum (AB-02-163) regarding the 2003 Clinical Laboratory Fee Schedule, CMS indicated that "due to concerns about beneficiary liability and implications for the Medicare Physician Fee Schedule," new codes 38207 through 38215 will be excluded from coverage. Instead, the 2003 Laboratory Fee Schedule will keep the old codes (88240 and 88241) for diagnostic purposes and include two G codes for therapeutic purposes (G0265, Cryopreservation, freezing and storage of cells for therapeutic use, each cell line; and G0266, Thawing and expansion of frozen cells for therapeutic use, each cell line).