Radiology Coding Alert

"Our clinic did the whole body imaging with 78802," Smith says.

"We did that twice, once when the patient first came in for the indium-111 and then when they came in for the second dose of yttrium-90," DeLioa says.

The Radiology Coder should report the scanning and the radiopharmaceutical drug, while the oncology department will be billing for the Rituxan, Smith says. Payment for infusion is packaged into the imaging scans and should not be billed separately.

Medicare is differentiating between hospitals and diagnostic centers, DeLioa says, "so as a free-standing diagnostic center, we are using A4641 (Diagnostic radiopharmaceutical), the drug name, and the NDC number." DeLioa says his facility is still waiting for clarification on drug codes, but for now, hospitals should use the J code for the indium-111 (J3490), while freestanding imaging centers should use A4641.

About one week after the initial treatment day, if all has gone well, the patient returns for a second intravenous infusion of rituximab (250 mg/m2) followed by yttrium-90 Zevalin, the therapeutic portion of the regimen. The radiation facility administers yttrium-90 Zevalin through an intravenous infusion lasting about 10 minutes.

For free-standing diagnostic centers, two codes are associated with this part of the treatment cycle, DeLioa and Smith say. Submit administration of the therapeutic dose with 79400 (Radiopharmaceutical therapy, nonthyroid, nonhematologic) and the radiation handling with 77790 (Supervision, handling, loading of radiation source). Medicare does not reimburse imaging studies after this infusion, according to a CMS Aug. 21, 2002, program memorandum (AB-02-120), but individual clinics may choose to do a second scan when the patient comes in for the yttrium-90 dose.

A code for radiation handling - 77750 (Infusion or instillation of radioelement solution) - appears in a potential coding sheet published by the pharmaceutical manufacturer IDEC, but not in Medicare guidelines, which state explicitly that "no other codes than the ones described & should be reported on claims for Zevalin."

Coding protocols for 78802 issued by Zevalin's manufacturer differ slightly from the CMS instructions in program memo AB-02-120. The main difference lies in the number of whole body scans recommended (up to three by IDEC) and the number reimbursed by Medicare.

CMS says that "only one of the three imaging codes should be used, with the units of service of one (1) that would include all the imaging studies performed, regardless of the number of images or number of days required to perform the imaging."

Though Medicare will only pay for one scan, some private insurance companies may reimburse for two, says Byron Hare, a representative specialist with IDEC's reimbursement hotline.

Some local carriers may also diverge from the literal application of Medicare guidelines. Smith says her office's local carrier (HGC Administrators) is telling her to bill for both scans (2 x 78802) because they're done on two different days. "We've submitted a claim based on that criteria with a -59 modifier (Distinct procedural service)," she says, but how reimbursement will shake out is still unknown. Coders should comb through LMRPs and have frank discussions with their local carriers about how often they may submit for imaging studies.

Smith says she has also contacted all the insurance companies that they work with prior to submitting claims. "I think that is important to reimbursement because we're not just sending a claim blindly. We also worked very closely with our pharmaceutical rep," she says.