Pathology/Lab Coding Alert

Stem-Cell Codes Add Up to Accurate Reimbursement

"New and improved" would be a fair moniker for stem-cell coding in 2003. With 13 new codes, pathologists involved in bone-marrow and peripheral-blood stem-cell services can finally account for each step of the complex procedures performed.

Specialized clinical centers around the country mainly use stem-cell transplant codes, says Samuel Silver, MD, PhD, medical director of the Cancer Center Network at the University of Michigan and representative of the American Society of Hematology to the AMA CPT Advisory Committee.

Pathology and laboratory services are integral to the stem-cell transplant process. Physicians use the procedure to treat many cancers and certain immunodeficiencies. Stem cells are "parent blood cells" that produce more stem cells and a supply of differentiated, mature blood components including red blood cells, white blood cells and platelets. Found in high concentration in bone marrow and lower concentration in blood, stem cells may be harvested, processed and reinfused into the same individual (autologous transplant) or into a different individual (allogenic transplant).

Although you have an entire list of new codes, using them is not difficult if you realize that they describe the three primary steps of stem-cell services: harvesting, processing/storage and transplanting. With one new code, CPT 2003 also acknowledges physician management of allogenic stem-cell transplant patients.

Source Is Key to Stem-Cell Harvesting Codes

Stem cells for transplantation may come from bone marrow or blood and from a self-donor or other donor. If you know the stem-cell source, you can code the harvesting procedure. CPT 2003 did not change the code for bone marrow harvesting: 38230 (Bone marrow harvesting for transplantation). Be sure not to report this service using codes for diagnostic bone marrow sampling, such as aspiration (38220) or biopsy (38221).

CPT 2003 has two new codes for blood stem-cell harvesting, which physicians perform using a process called cytapheresis. The procedure involves collecting blood, separating the stem cells, and immediately returning the remaining cells to the patient. The new codes are:

These replace deleted code 38231 (Blood-derived peripheral stem cell harvesting for transplantation, per collection).

"Multiple cytapheresis sessions are often necessary to collect sufficient stem cells for transplantation," says Kevin Bundy, BB, MT, SBB (ASCP), CLS (NCA), supervisor of the Human Cellular Therapy Laboratory at the Mayo Clinic in Rochester, Minn. Report each session separately using appropriate code 38205 or 38206. Do not report cytapheresis for stem-cell transplantation using the other new therapeutic apheresis codes 36511-36516 (see "CPT 2003 Infuses Lifeblood Into Apheresis Codes" in article 2).

List Each Step to Process and Store Stem Cells

"One code to list them all" was the rule for stem-cell modification to eliminate cell types prior to CPT 2003. Now four specific codes replace deleted code 86915 (Bone marrow or peripheral stem cell harvest, modification or treatment to eliminate cell type[s] [e.g., T-cells, metastatic carcinoma]). These four codes are part of the new 38207 family indented under the words Transplant preparation of hematopoietic progenitor cells:

Preventing graft/host disease might entail stem-cell processing to reduce T-cells, for example, which you should report using 38210, Bundy says. Some clinical situations may require treatment for more than one cell type, such as positive selection to obtain CD 34 (progenitor cells) that also results in T-cell depletion as a consequence, Bundy says. "Whether to report one code for the primary reason for the treatment, or two codes for the two cell types eliminated may depend on payer direction."

Other new codes in the 38207 family describe various processing steps such as freezing, storing, thawing, washing and concentrating the stem cells:

Prior to the addition of 38207, coders reported stem-cell cryopreservation using 88240 (Cryopreservation, freezing and storage of cells, each cell line) and stem-cell thawing using 88241 (Thawing and expansion of frozen cells, each aliquot). Although CPT 2003 does not delete codes 88240 and 88241, text notes indicate that you should use them only for diagnostic cryopreservation, storage and thawing. Do not use them for therapeutic stem-cell transplant freezing and storage.

Essentially, new CPT stem-cell codes describe in greater detail what bone-marrow-transplant physicians and technicians do, anticipating more billing and tracking issues in the future, Silver says. "We will probably see more stand-alone, nonfacility stem-cell laboratories that can now bill for all the different steps they take rather than lumping them into a single process."

Infusion Type Determines Transplant Code

CPT 2003 does not change the two codes for stem-cell transplantation, which you should assign based on whether the transplant is allogenic or autologous:

38240 Bone marrow or blood-derived peripheral stem cell transplantation; allogenic

38241 autologous.

CPT 2003, however, did add new infusion code 38242 ( allogeneic donor lymphocyte infusions). Before the addition of this code, labs had to bill 38240 for lymphocyte infusions, a risky procedure dealing with allergic reactions in allogenic transplant patients. With the creation of separate stem-cell and lymphocyte infusion codes, "weve defined a procedure thats commonly done after a bone marrow transplant and provided a code that will appropriately describe that procedure," Silver says.

Management Code Acknowledges Physician Oversight

Perhaps the most significant addition to the stem-cell transplant codes is 38204 (Management of recipient hematopoietic progenitor cell donor search and cell acquisition). For the first time, CPT acknowledges the work involved in physician oversight of finding and acquiring donor cells. Physicians may bill once per transplant for unrelated bone marrow donor management.

Even if you dont use this code every day, the management codes introduction will become increasingly important when gene therapies enter into the everyday clinical world, Silver believes. There are "all kinds of stuff coming down the pike that will constitute individualized, specific cellular therapy for patients." Assigning a reimbursable value to these "cognitive services" could be significant for the future of pathology coding.

Medicare Disregards New Codes

The new stem-cell transplant codes allow billers to add up the specific services rendered throughout the entire process unless the payer is Medicare. In a recent program memorandum (AB-02-163, Nov. 8, 2002) regarding the 2003 Clinical Laboratory Fee Schedule (CLFS), CMS indicated that "due to concerns about beneficiary liability and implications for the Medicare Physician Fee Schedule," it would exclude new codes 38207 through 38215 from coverage.

Instead, the 2003 CLFS includes three new HCPCS Level II codes for therapeutic stem-cell freezing, processing and thawing. The new G codes are listed below, along with the CPT codes they replace for Medicare billing:

G0265 Cryopreservation, freezing and storage of cells for therapeutic use, each cell line

Use this code instead of new CPT code 38207. Continue to use 88240 for diagnostic purposes.

Use this code instead of new CPT code 38208. Continue to use 88241 for diagnostic purposes.

This code replaces deleted code 86915; use this code instead of new CPT codes 38210-38213.