Urology Coding Alert

Combine research and billing system edits to boost accuracy.

To stay on top of Medicare's constantly changing Provenge coding rules, you need a solid strategy.

One place to start is the manufacturer's website, says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill. "Take advantage of their specialized knowledge and assistance when offered, especially when an office or facility initially starts using the product," Martin says. You'll find the website at www.provengereimbursement.com/.

Of course, you will want to check what the manufacturer says against payer policies. You can search your payer's site, or the Provenge reimbursement website, which offers links to "state-specific coverage information, and there is an external link to the Medicare NCD [National Coverage Determination] from their website, which also contains very specific information" says Martin.

Provenge policies are indeed 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 use, Martin notes. If you leave off one of the required codes, you can expect reimbursement issues, she adds.

Example: A patient covered by Palmetto GBA presents 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 administers Provenge over the course of 61 minutes. Per payer policy, you should report:

• Q2043, Sipuleucel- T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion
• 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• 185, Malignant neoplasm of prostate
• 196.1, Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes.

(To see the J1 Palmetto GBA article in full, go to www.palmettogba.com/medicare. In the search box, choose J1 Part B and enter the article title: "New HCPCS Code for Provenge." The results page will show the link for that article.)

Tech tactic: "When possible, I recommend building drug-specific billing edits within your billing system to catch those claims that do not meet both primary and secondary diagnosis requirements so that these can be corrected (when and if appropriate) before the claim is filed," says Martin.