Pulmonology Coding Alert

Photodynamic therapy (PDT) is a nonsurgical procedure gaining acceptance with pulmonologists across the country for treating patients with lung cancer. This treatment is a three-step process. First, the patient is given an injection of a photosentizing agent. Then, after an appropriate waiting period, the pulmonologist performs a bronchoscopy, and in the final step, a laser is used to remove or destroy the cancerous cells.

The key to receiving full and prompt reimbursement for this procedure from Medicare and other carriers is to make sure each step is coded correctly. To achieve this, two add-on codes, 96570-96571, were created for a special photodynamic therapy subsection in the CPT 2001 manual. According to Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. Prior to these additions, there were no accurate codes available for this procedure; consequently, practices were left to use unlisted codes and submit claims in hard copy with the appropriate documentation. Given the burden of paper claims, coders have welcomed these two codes.

The First Step: The Intravenous Injection

A patient presents to the pulmonologists office where he receives an intravenous injection of a photoactive drug. This first step is reported using 90784 (therapeutic prophylactic or diagnostic injection [specify material injected]; intravenous), with the drug code J3490.

According to Peter Tanaka, CPC, vice president of data development at Unicore Medical, a company that publishes ICD-9 coding books and software in Montgomery, Ala., the physician, while he supervises the treatment, does not have to administer the medication; a nurse can do it. This step is coded as incident to because it is performed as though the physician has administered it and it meets these general guidelines accepted by Medicare in this situation:

1. The physician has established the treatment plan for this particular patient; and

2. The nurse is acting under the direct supervision of the doctor, who must be within the office space although not necessarily in the room.

Note: Availability by telephone does not meet this requirement.

The Second Step: Bronchoscopy

About two days later, the patient returns to the doctors office. This waiting period has given the photosensitizing agent time to leave the healthy cells but to remain in the cancerous ones. The fiberoptic that will destroy the cancerous cells is now directed through a bronchoscope into the patients lung. This procedure is reported using 31641 (bronchoscopy; with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser).

The Third Step: Laser Use

Finally, the laser is activated, and the light source applied to the patients cancerous cells. This is reported using the two new add-on codes 96570 and 96571. Both codes cover photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drugs(s). Code 96570 applies to the first 30 minutes, and 96571 to each additional 15 minutes of illumination. Code 96570 can be used only once on the date of service, and 96571, as many times as needed. However, if the additional PDT time above the first 30 minutes does not reach 15, 96570 cannot be billed.

The CPT manual states these two codes are to be used with 31641. As Callaway explains, Since these codes represent additional work in activating the drug that is above and beyond that reflected in a basic bronchoscopy, they must be added to it. To clarify the coding further, Tanaka adds that modifier -51 (multiple procedures) is not needed because these are add-ons.

Coding Example

A 40-year-old man with a 20-year history of smoking is diagnosed with chronic obstructive lung disease (496). He develops a severe cough, and his septum is flecked with blood. He uses supplemental oxygen and has trouble breathing when climbing stairs. The initial diagnosis shows an area of cancerous cells in his left bronchus (eg., 162.2 primary malignant neoplasm of the main bronchus), and since a pulmonary function test indicates he is not a viable surgical or radiation candidate, PDT becomes the treatment of choice.

When the patient presents to the doctors office, the nurse gives him an intravenous injection of a photoactive drug, and it is coded 90784. He is then sent home with the proper healthcare instructions and told to return in 48 hours. At that time a bronchoscope is passed into his left bronchus, and the laser is activated for 45 minutes, ablating the cancerous cells. These last two steps would be reported using 31641 for the bronchoscopy, 96570 for the first 30 minutes of laser treatment, and 96571 x 1 for the final 15 minutes. If the patient had received a total of 60 minutes of laser treatment, the procedure would be coded as 31641, 96570, and 96571 x 2.

Detection of Additional Unexpected Cancer Cells

If the physician detects a previously undiagnosed area of cancerous cells during the PDT, the only code that can be used more than once is 96571, indicating use of a laser beyond the initial 30 minutes; neither the bronchoscopy nor the injection code can be billed twice. For example, a 65-year-old male who has been diagnosed with cancer of the left bronchus presents for his scheduled PDT. Forty-five minutes of laser treatment destroys the cancerous cells. However, as the physician removes the bronchoscope, he detects an area of cancer in the right bronchus that he ablates using an additional 30 minutes of laser. The pulmonologist would report the first two steps of the procedure using J3490 and 31641. Code 96570 would be added on for the first 30 minutes of laser treatment on the left lung, and 96571 x 3 for the last 15 minutes for treatment on the left lung and the 30 minutes for the right.

Discontinued Procedure

Modifier -74 (discontinued outpatient hospital/ ambulatory surgery center [ASC] procedure after administration of anesthesia) can be added if the pulmonologist discontinues the procedure because of threats to the patients health. For example, having received an injection of a photoactivating drug 48 hours ago, a patient diagnosed with cancer of the right bronchus presents for a scheduled bronchoscopy and laser treatment. The physician notices that the patients breathing has become more labored in the last two days, but decides to continue the treatment. However, once the bronchoscope is passed into the right bronchus, the patient becomes too distressed to continue. The coding would be 31641-74, indicating that the procedure had been terminated because of extenuating circumstances. In addition to limiting the billing to only the bronchoscopy, this alerts the carrier that the procedure may be tried at a later date.

Note: According to Dari Bonner, CPC, CPC-H, CCS-P, president/owner, Exact Coding & Reimbursement Inc.,Port St. Lucie, Fla., Florida Medicare and private carriers are recognizing these two new add-on codes and paying them accordingly. If a rejection is received from a third-party payer, she recommends checking for the possibility of modifier application per medical record documentation or checking to ensure they recognize the code in their system. Certain edits for a new procedure present in a carriers system may simply require calling the payer to ensure they have been added.