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Practice Management Alert

Reader Question:

Review Payer-Specific Policies for Provenge Billing

Published on Wed Apr 18, 2012

Question: A patient covered by Palmetto GBA presented for his first dose in the treatment regimen. He has been diagnosed with minimally symptomatic castrate-resistant (hormone refractory) prostate cancer that has metastasized to the intrathoracic lymph nodes and meets the other requirements for coverage. Staff administered Provenge over the course of 61 minutes. How should I bill or this service?South Carolina SubscriberAnswer: Per payer policy, you should bill: Q2043, Sipuleucel- T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour185, Malignant neoplasm of prostate196.1, Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes. Provenge reimbursement and billing policies are very specific, so reading the national and local policies in full is important. For instance, Provenge has both primary and secondary diagnosis coding requirements for on-label [...]
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