Radiology Coding Alert

Understand the different codes for diagnostic and therapeutic procedures

When your radiation oncologist or nuclear medicine specialist uses the anti-cancer drug Zevalin (ibritumomab tiuxetan) for radiopharmaceutical treatments, you should choose either 78804 or CPT 79403 based on the nature of the service: either diagnostic or therapeutic.

Typically, physicians use Zevalin along with the drug RituXan (J9310) as a single course of treatment on patients with non-Hodgkin's lymphoma (for example, 202.8x, Other lymphomas) who have not responded to conventional chemotherapy or have relapsed.

Because Medicare hasn't issued national guidelines on Zevalin therapy, you should follow your local carrier's specific coding policies. But typically, you should use 78804 (Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent[s]; whole body, requiring two or more days imaging) if the physician localizes a tumor or distributes Zevalin throughout the whole body. The study generally requires more than two days of imaging.

To report the diagnostic dose of Zevalin in an office or freestanding center, you should use A9522 (Supply of radiopharmaceutical diagnostic imaging agent, indium-111 ibritumomab tiuxetan, per mci) for one unit of service.

Tip: Code 78804 usually represents the physician's diagnostic services, radiation oncology coding experts say. Even if the radiation oncologist performs multiple days of radiopharmaceutical testing, report 78804 only once.

Here's why: According to the Mutual of Omaha local coverage determination, "The procedure encompasses the administration of Indium-labeled Zevalin and whole body radionuclide scanning 2-24 hours and 48-72 hours after the administration of Zevalin. ... The purpose of the scanning is to ensure that the biodistribution of Zevalin is normal, thus decreasing the risk of toxic effects from administration of a therapeutic dose of Zevalin."

In rare cases, patients may also require a third set of images at 90-120 hours. After providing review and oversight during the entire study, the physician personally supervises a slow infusion of the monoclonal antibody, watching for potential reactions. The physician should also make sure images are free of motion and artifacts.

After the second or third set of images, the physician will compare the images, which is why you report only one code. Your documentation should include the complete interpretation and report, along with information about who performed the injections and how long it took.

Many Medicare carriers, such as Group Health NY, maintain that you shouldn't report therapeutic radiophar-maceutical administration separately, because the carrier includes the service in the overall procedure codes. Typically, you can expect a Medicare insurer to pay about $240 for 78804.

When the radiation oncologist delivers Zevalin in an office or freestanding center through monoclonal antibody therapy to the non-Hodgkin's lymphoma patient, you should report 79403 (Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion) and A9523 (Supply of radiopharmaceutical therapeutic imaging agent, yttrium 90 ibritumomab tiuxetan, per mci).

Important: Code 79403 represents the therapeutic portion of the radiopharmaceutical therapy. Nationally, Medicare pays about $300 for the code.

You should assign the code once in addition to the charge for 78804. Code 78804 represents the physician's diagnostic services. Only the physician who performs and documents the service should bill for the administration of either the therapeutic or diagnostic procedure.

Remember: Code 79400 (Radiopharmaceutical therapy, nonthyroid, nonhematologic by intravenous injection) includes the infusion and supervision services that 79403 represents, so you should not report these codes separately.

If you report 78804 and 79403 together, your Medicare and private carrier will likely require that patients meet several criteria to be eligible for the radiation therapy.

For example, HGS Administrators, Pennsylvania's Medicare payer, requires that patients have the following: