1. Review Of New CPT Codes Affecting BMT Services
Presented by: James L. Gajewski, M.D.

2. Disclaimer: Please note that the opinions expressed in this presentation are those of the presenter and, as such, are intended as guidance only. As always, final interpreta-tion of the requirements of any code, including the acceptability of billing and documentation practices, rests in the domain of the private payer or authorities of the Centers for Medicare and Medicaid Services.

3. Overview Background Review new codes and CMS issues
Critical care E&M issues
Future concerns

4. Background

5. Abbreviations CPT = Current Procedural Terminology
RVU = Relative Value Units
HCPCS = Healthcare Common Procedure Coding System

6. Committees CPT Editorial Panel RVU-RBRVS Update Committee (RUC)
Outpatient Practice Expense – Practice Expense Allocation Committee (PEAC)

7. Coalition To Address Coding Deficiencies
Sponsor: American Society of Hematology
Co-Sponsors:
American Society for Blood and Marrow Transplantation
American Association of Blood Banks
International Society of Cellular Therapy
The National Marrow Donor Program
American Society of Clinical Oncologists
American Red Cross
Exempt Cancer Centers Committee
Foundation for Cellular Therapies

8. New Billing Regulations
One price per CPT code
per patient bill

9. Old Codes Are Inadequate
Apheresis Apheresis
Plasma Pheresis
Cell Processing T- and B-cell Removal ; Cross-reference to and for cryopreservation and thawing

10. CPT editorial committee has been trying to enhance “granularity” of CPT
Most patient bills need either HCPCS Level I better known as CPT codes OR
HCPCS Level II codes attached to services for electronic billing of services

11. Review Of New Codes Rationale behind request Facility related expenses
Physician professional component
Documentation necessities

12. Apheresis Therapeutic apheresis: 36511 For white blood cells
For red blood cells
36513 For platelets
For plasma pheresis
With extracorporeal immunoadsorption and plasma reinfusion
With extracorporeal selective adsorption or selective filtration and plasma reinfusion

13. Apheresis Rationale
Different costs of disposables for different procedures
Different types of personnel using procedures that are commonly performed on emergent basis
Different level of physician involvement for different procedures

14. Apheresis Facility Related Expenses
All apheresis codes are billed as facility based
Each procedure has separately priced disposables
Each code has the appropriate technical component to assure appropriate billing
e.g. time for performing a white blood cell or plasma exchange may be greater than a red blood cell or platelet exchange

15. Apheresis Facility Related Expenses
For governmental payers, these procedures can only be billed from hospital based inpatient or outpatient facilities
Project for future is PEAC survey for these services so that free standing facilities can bill governmental payers

16. Apheresis Physician Professional Component
Physician work effort surveys were done but RUC did not approve of the surveys
Each apheresis procedure has an RVU of 1.74
The RVU for may be decreased to 1.22 in 2004

17. Apheresis Professional Billing Criteria
Procedural professional fee does not require physician to do procedure, but requires physician to examine patient during procedure and demonstrate active supervision of procedure.
Physician must be available. Available means within hospital during entire procedure. This does not mean the physician must remain in pheresis unit.

18. Apheresis Professional Billing Criteria
Evaluation of patients for apheresis is billable separately as long as it is done on a different day. This is billed on consult H&P.
Post-procedure follow-up is also billable separately as long as it is done on a different day, following E&M service.
For inpatients, different physicians from same specialty may bill service on the same day. Hematologists follow acute leukemia on inpatients and different hematologists perform apheresis procedures.

19. Billing for apheresis services would be easier if apheresis was recognized as a unique specialty!

20. Donor Search and Transplant Product Acquisition
38204 Management of recipient hematopoietic progenitor cell donor search and cell acquisition

21. Donor Search and Transplant Product Acquisition – 38204 Physician Professional Component
For physician supervision of donor search coordinators identifying an unrelated donor and communicating with donor center medical directors and the harvesting physicians. This code is also to be used for cord blood searches. Patient contact is not necessary for this code to be billed.

22. Donor Search and Transplant Product Acquisition – 38204 Facility Related Expenses
This donor search CPT code may not be used for NMDP/Cord Blood Registry donor services on product acquisition.
On patient bills, these services should either have no CPT attached or a generic CPT code such as
Future task is to create HCPCS Level II codes for these services.

23. Donor Search and Transplant Product Acquisition – 38204 Facility Related Expenses
The donor search code will usually be billed once. This may be billed for successful and unsuccessful searches.
If a search goes to BMT, the BMT fails and a new search is done for a new donor, this code may be billed twice.
If a DLI or boost from the same donor is used, then this code may not be billed twice.

24. Donor Search and Transplant Product Acquisition – 38204
Medicare chose not to recognize this code. Medicare felt the service should be valued under infusion CPT
Appeal is underway.

25. Stem Cell Collection
38205 Blood derived hematopoietic progenitor cell harvest for transplantation; allogeneic
38206 Blood derived hematopoietic progenitor cell harvest for transplantation; autologous

26. Stem Cell Collection – 38205 & 38206 Rationale
The old codes were split due to expenses for donor evaluation

27. Stem Cell Collection – 38205 & 38206 Facility Related Expenses
Both codes cover the collection services for one day’s collection.
Multiple day’s services require multiple uses of this code.

28. Stem Cell Collection – 38205 & 38206 Facility Related Expenses
For governmental payers, i.e. Medicare or Medicaid, these services are facility based.
They can only be billed from hospital based inpatient or outpatient collection facilities. This does not apply to non-governmental payers.
If we try to make these codes not-facility based, the issue is whether nurse time can be attached to practice expense or must be allocated to professional fee. This needs to be better understood before doing a PEAC survey

29. Stem Cell Collection – 38205 & 38206 Suggested Facility Related Expenses
The pricing of the service may include:
Nurse/technician time, machine disposables, machine depreciation, space utilized and all costs associated with meeting regulatory requirements.

30. Stem Cell Collection – 38205 & 38206 Physician Professional Component
Physicians may bill for this procedure even if not doing the procedure. RVU valuation was for physician supervision of nurse/ technician performing the procedure. To bill, the physician must document exams during procedures and supervision of staff for a particular patient. Physician must remain within hospital for entirety of procedure and be immediately available. The physician does not need to be in the apheresis unit for entirety of procedure.
This is a per-day physician charge for management of collection. For multiple day collections, these codes may be be billed on multiple days.

31. Allogeneic Stem Cell Collection – 38205 Physician Professional Component
Allogeneic donor assessment for apheresis should be new patient – not consult H&P (there is not referring physician).
Follow-up after care on a different day may use follow-up E&M codes.

32. Autologous Stem Cell Collection – 38206 Physician Professional Component
Autologous pre-stem cell collection may be billed as a consult H&P if the physician doing apheresis is different from the physician managing the cancer care. This can be a “within specialty” consult; however, this consult cannot be done on the day of collection. Wording of consult is important-or it will be a referral-transfer of care.
Autologous post-proceeding assessment is billable by E&M codes for follow-up as long as by different physicians doing routine cancer care. This cannot be billed on the day of collection.

33. Cell Processing

34. Cell Processing Rationale
Allow granularity for cell processing so that we do not utilize the old for red blood cell depletion
Codes moved to join other BMT related codes in CPT manual
Removed reference to and which were designed for laboratory diagnostic procedures not therapeutic transplant services

35. Cell Processing Codes Rationale
CPT would only give codes to procedural processes that are accepted
T-cell depletion and tumor purging have codes but not CD34 selection
Stem cell expansion still in research and we cannot set code for this service

36. Cell Processing Generic Facility Pricing Issues
These are per day codes
Markets sets prices, but in assessing cost to determine institutional pricing consider including:
Technician time, supplies, machine use, machine depreciation, space costs, malpractice risk, quality assurance testing of an individual product, overhead
Pricing may include amortization of GMP laboratory construction cost but must be amortized over 10 years
RVU-RBRVS Committee established temporary RVU’s for all of these codes, but CMS chose not to recognize these rvu’s

37. Cell Processing Physician Work Effort
Includes:
Review of data important for cell processing decisions
Supervision of technicians performing an individual patient’s cell processing
Review and interpretation of quality assurance procedures for an individual patient’s cells being processed, including flow cytometry
Report on product adequacy and ability of cellular product to meet expectations
Time for report preparation and review of cell processing
Malpractice risk
Psychological stress

38. Cell Processing
38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage

39. Cell Processing – 38207 Suggested Facility Related Expenses
For cryopreservation and storage of bone marrow or peripheral blood progenitor cells.
Facility fees include tech time, laboratory supplies, machinery, machinery depreciation, and space costs.
If mononuclear cell processing was done prior to
cryopreservation, it should be billed separately.
Cryopreservation charge should include all quality
assurance testing.
After 2004, this code will include billing for all flow
cytometry tests used for quality assurance testing.

40. Cell Processing – 38207 Physician Professional Component
Planning for cryopreservation
How many stem cells or T-cells will be stored to meet needs of transplant?
What are anticipated issues?
Donor-recipient HLA/ABO/infectious disease serology, recipient/donor size disparity
What is RBC contamination of product?
Which quality assurance procedures will be performed?
CD34, CD3 tests
Microbiology testing
Technician supervision
Review of freezer curves
Report generation to review adequacy of cryopreserved product and the product’s ability to meet specifications

41. Cell Processing
38208 Transplant preparation of hematopoietic progenitor cells; thawing of a previously cryopreserved progenitor cell harvest

42. Cell Processing – 38208 Suggested Facility Related Expenses
For thawing of harvest on the day of infusion
Includes all equipment, equipment depreciation, space costs, and technician time used in thawing process
Post thaw viability testing

43. Cell Processing – 38208 Physician Professional Component
Includes:
Review of patient/donor data, freezer curves, adequacy of cryopreserved product
Supervision of thawing, quality assurance testing of pre- and post-thaw product i.e. viability testing flow cytometry (obviously this does not hold up thaw)
Need for special procedures for thawing processes i.e. need for wash; concerns for incompatible RBC contamination
Report on product adequacy and ability to meet specifications
Preparation time for a thaw report
After 2004, flow cytometry will not be billed separately

44. Cell Processing 38209 Transplant preparation of
hematopoietic progenitor cells; washing of
a previously cryopreserved progenitor cell
harvest

45. Cell Processing – 38209 Rationale and Suggested Facility Fee Issues
For 2003, this is only for thawed cells requiring a wash to remove DMSO
Facility fee should include technician time, machinery, supplies and machinery depreciation
Post-wash viability testing
In 2004, this code will be redesigned for thawing without wash and thawing with wash

46. Cell Processing – 38209 Physician Professional Component
Technician supervision of process
Quality assurance of product after wash
Report generation to review adequacy of product and product’s ability to meet transplant specifications

47. Cell Processing
38210 T-Cell Depletion

48. Cell Processing – 38210 Suggested Facility Related Expenses
Facility fees may include machinery, machinery depreciation, technician time, supplies, space costs, and quality assurance testing
If cryopreservation is needed, it may be billed separately
If mononuclear cell separation not usually done prior, then may be billed separately
Tests to evaluate efficacy of T-cell depletion
Tests to evaluate viability after T-cell depletion
In 2004, will include flow cytometry testing, pre and post

49. Cell Processing – 38210 Physician Professional Component
Assess donor/recipient suitability for T-cell depletion
Assess HLA typing, donor/recipient size disparity
Assess quality of product coming to lab for T-cell depletion, cell number, CD34 count, CD3 counts
Supervision of technician performing processing
Assessment of efficacy of T-cell depletion
Review and interpretation of quality assurance testing
Report preparation on quality of product to meet specifications

50. Cell Processing
38211 Tumor cell depletion

51. Cell Processing – 38211 Suggested Facility Related Expenses
For autologous transplantation
Facility fees may include machinery, machinery depreciation, technician time, supplies, space costs and quality assurance testing
Testing to document efficacy of tumor purging
Testing to document post-tumor purging cell viability
Cryopreservation is always done and therefore should not be billed separately
If mononuclear cell separation is always done, it should be included in pricing; if not, do not include in pricing
After 2004, flow cytometry assessment must be included in pricing and cannot be billed separately

52. Cell Processing – 38211 Physician Professional Component
Assessment of need for tumor purging
Assessment of quality of product for tumor purging
Supervision of technician performing tumor purging
Assessment of efficacy of tumor purging
QA testing and review
Report preparation on quality of product and that product meets specifications requested

53. Cell Processing
38212 Red blood cell removal

54. Cell Processing – 38212 Suggested Facility Related Expenses
For a fresh allogeneic harvest; removal of RBC’s in preparation for transplant
Facility fees may include tech time, supplies, machinery and red cell depletion for a major ABO incompatible bone marrow harvest
Testing of efficacy of RBC removal
Testing of viability of progenitor cells after RBC removal
In 2004, will include price for flow cytometry testing for quality assurance

55. Cell Processing – 38212 Physician Professional Component
Review of ABO typing prior to harvest
Supervision of the process
Review of quality assurance testing
Report preparation that product meets or does not meet specifications

56. Cell Processing
38213 Platelet depletion

57. Cell Processing – 38213 Rationale
For peripheral blood progenitor cell harvest with a platelet soft spin
No RVU’s are assigned to this code because no physician assessment is done for quality of platelet addback given to any donor with low platelet counts

58. 38214 Plasma/volume depletion
Cell Processing
38214 Plasma/volume depletion

59. Cell Processing – 38214 Suggested Facility Related Expenses
For a fresh bone marrow harvest and for plasma removal
Facility fees may include technician time, supplies, and machinery
For viability testing after plasma removal
For 2004, will include flow cytometry testing for quality assurance of product

60. Cell Processing – 38214 Physician Professional Component
Review of donor/recipient size and ABO blood types
Quality assurance of product
Supervision of cell processing
Report generation of product meets or does not meet specifications

61. 38215 Cell concentration of plasma, mononuclear, or buffy coat layer
Cell Processing
Cell concentration of plasma, mononuclear, or buffy coat layer

62. Cell Processing – 38215 Rationale
For mononuclear cell preparation for major/minor ABO incompatibility on a fresh bone marrow harvest or for further cell processing procedures
For occasional mononuclear cell separation for further manipulation, if this is not routinely done for additional procedures then mononuclear cell preparation may be billed separately

63. Cell Processing – 38215 Physician Professional Component
Review of donor/recipient ABO incompatibility
Supervision of cell processing
Quality assurance testing
Report preparation

64. 38242 Donor Lymphocyte Infusion
This code is to administer a post allogeneic donor lymphocyte infusion to treat relapse of malignancy or infection after allogeneic bmt.
For boost of progenitor cells to treat pancytopenia still use 38240, the allogeneic transplant infusion code.

65. CMS Issues

66. The Unprocessed Stem Cells
CPT editorial board refused our request for a code for generic quality assurance testing
Only option is for those patients to continue to bill those services under 38240, 38241, and 38242

67. CMS Issues
CMS did not approve these cell processing codes and the code for unrelated donor search and organ acquisition and 38204s
These codes can be used to bill these services to non-governmental payers
CMS has always had difficulty paying for organ acquisition costs
CMS moved these codes to to G-code section of HCPCS Level II and will pay for cryopreservation and storage at rate for and 88241

68. CMS Issues
With the new codes we probably are better off with the non-governmental payers
With CMS, we are no worse off
Work on these codes brought increased scrutiny to all apheresis and BMT related cost
These codes were presented as facility based. To do practice expensing would require a survey of how may pipettes, 4x4’s, we all use for every procedure

69. Critical Care E&M Issues

70. Critical Care
Critical care can billed for service rendered for patient not in MICU
Advantage of critical care for E&M is that it is a time based code.
Critical care pays more RVU’s than most complex inpatient E&M code (4 vs. 1.51, respectively)

71. Critical Care
Critical care is direct delivery by a physician of medical care for a critically ill or critically injured patient.
A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
CPT 2003, Professional Edition

72. Critical Care
Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or prevent further life threatening, deterioration of the patient’s condition.
CPT 2003, Professional Edition

73. Future Concerns

74. Future Concerns No one is totally satisfied with the results
Billing these new codes will require more time and effort
Billing is moving to electronic transmittal of data. Each item in bill needs either a CPT code or HSPCS level II code
Billing these codes is important in case rate payments because underlying charges determine how case rate payment is allocated within institutions. Even if bill is paid as case rate, third party payers are to receive itemized bill.

75. Future Concerns
The January 26, 2003, edition of the New York Time’s indicated we and our hospitals cannot expect to charge as much as we are to pharmaceuticals. We will need these services with legitimate costs adequately to justify current case rates.

76. ASBMT and the bmt community owes a great debt for the service of Samuel Silver, M.D., Ph.D. and ASH staff
Their ongoing labors for financial issues have not received the national accolades they deserve