Presentation on theme: "Review Of New CPT Codes Affecting BMT Services"— Presentation transcript:
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 issuesFuture concerns
5 Abbreviations CPT = Current Procedural Terminology RVU = Relative Value UnitsHCPCS = 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 HematologyCo-Sponsors:American Society for Blood and Marrow TransplantationAmerican Association of Blood BanksInternational Society of Cellular TherapyThe National Marrow Donor ProgramAmerican Society of Clinical OncologistsAmerican Red CrossExempt Cancer Centers CommitteeFoundation for Cellular Therapies
8 New Billing Regulations One price per CPT codeper patient bill
9 Old Codes Are Inadequate Apheresis ApheresisPlasma PheresisCell 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 codesORHCPCS Level II codes attached to services for electronic billing of services
11 Review Of New Codes Rationale behind request Facility related expenses Physician professional componentDocumentation necessities
12 Apheresis Therapeutic apheresis: 36511 For white blood cells For red blood cells36513 For plateletsFor plasma pheresisWith extracorporeal immunoadsorption and plasma reinfusionWith extracorporeal selective adsorption or selective filtration and plasma reinfusion
13 Apheresis RationaleDifferent costs of disposables for different proceduresDifferent types of personnel using procedures that are commonly performed on emergent basisDifferent level of physician involvement for different procedures
14 Apheresis Facility Related Expenses All apheresis codes are billed as facility basedEach procedure has separately priced disposablesEach code has the appropriate technical component to assure appropriate billinge.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 facilitiesProject 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 surveysEach apheresis procedure has an RVU of 1.74The 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 asFuture 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 CPTAppeal is underway.
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.
34 Cell Processing Rationale Allow granularity for cell processing so that we do not utilize the old for red blood cell depletionCodes moved to join other BMT related codes in CPT manualRemoved 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 acceptedT-cell depletion and tumor purging have codes but not CD34 selectionStem cell expansion still in research and we cannot set code for this service
36 Cell Processing Generic Facility Pricing Issues These are per day codesMarkets 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, overheadPricing may include amortization of GMP laboratory construction cost but must be amortized over 10 yearsRVU-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 decisionsSupervision of technicians performing an individual patient’s cell processingReview and interpretation of quality assurance procedures for an individual patient’s cells being processed, including flow cytometryReport on product adequacy and ability of cellular product to meet expectationsTime for report preparation and review of cell processingMalpractice riskPsychological stress
38 Cell Processing38207 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 tocryopreservation, it should be billed separately.Cryopreservation charge should include all qualityassurance testing.After 2004, this code will include billing for all flowcytometry tests used for quality assurance testing.
40 Cell Processing – 38207 Physician Professional Component Planning for cryopreservationHow 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 disparityWhat is RBC contamination of product?Which quality assurance procedures will be performed?CD34, CD3 testsMicrobiology testingTechnician supervisionReview of freezer curvesReport generation to review adequacy of cryopreserved product and the product’s ability to meet specifications
41 Cell Processing38208 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 infusionIncludes all equipment, equipment depreciation, space costs, and technician time used in thawing processPost thaw viability testing
43 Cell Processing – 38208 Physician Professional Component Includes:Review of patient/donor data, freezer curves, adequacy of cryopreserved productSupervision 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 contaminationReport on product adequacy and ability to meet specificationsPreparation time for a thaw reportAfter 2004, flow cytometry will not be billed separately
45 Cell Processing – 38209 Rationale and Suggested Facility Fee Issues For 2003, this is only for thawed cells requiring a wash to remove DMSOFacility fee should include technician time, machinery, supplies and machinery depreciationPost-wash viability testingIn 2004, this code will be redesigned for thawing without wash and thawing with wash
46 Cell Processing – 38209 Physician Professional Component Technician supervision of processQuality assurance of product after washReport generation to review adequacy of product and product’s ability to meet transplant specifications
48 Cell Processing – 38210 Suggested Facility Related Expenses Facility fees may include machinery, machinery depreciation, technician time, supplies, space costs, and quality assurance testingIf cryopreservation is needed, it may be billed separatelyIf mononuclear cell separation not usually done prior, then may be billed separatelyTests to evaluate efficacy of T-cell depletionTests to evaluate viability after T-cell depletionIn 2004, will include flow cytometry testing, pre and post
49 Cell Processing – 38210 Physician Professional Component Assess donor/recipient suitability for T-cell depletionAssess HLA typing, donor/recipient size disparityAssess quality of product coming to lab for T-cell depletion, cell number, CD34 count, CD3 countsSupervision of technician performing processingAssessment of efficacy of T-cell depletionReview and interpretation of quality assurance testingReport preparation on quality of product to meet specifications
51 Cell Processing – 38211 Suggested Facility Related Expenses For autologous transplantationFacility fees may include machinery, machinery depreciation, technician time, supplies, space costs and quality assurance testingTesting to document efficacy of tumor purgingTesting to document post-tumor purging cell viabilityCryopreservation is always done and therefore should not be billed separatelyIf mononuclear cell separation is always done, it should be included in pricing; if not, do not include in pricingAfter 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 purgingAssessment of quality of product for tumor purgingSupervision of technician performing tumor purgingAssessment of efficacy of tumor purgingQA testing and reviewReport preparation on quality of product and that product meets specifications requested
54 Cell Processing – 38212 Suggested Facility Related Expenses For a fresh allogeneic harvest; removal of RBC’s in preparation for transplantFacility fees may include tech time, supplies, machinery and red cell depletion for a major ABO incompatible bone marrow harvestTesting of efficacy of RBC removalTesting of viability of progenitor cells after RBC removalIn 2004, will include price for flow cytometry testing for quality assurance
55 Cell Processing – 38212 Physician Professional Component Review of ABO typing prior to harvestSupervision of the processReview of quality assurance testingReport preparation that product meets or does not meet specifications
57 Cell Processing – 38213 Rationale For peripheral blood progenitor cell harvest with a platelet soft spinNo 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
59 Cell Processing – 38214 Suggested Facility Related Expenses For a fresh bone marrow harvest and for plasma removalFacility fees may include technician time, supplies, and machineryFor viability testing after plasma removalFor 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 typesQuality assurance of productSupervision of cell processingReport generation of product meets or does not meet specifications
61 38215 Cell concentration of plasma, mononuclear, or buffy coat layer Cell ProcessingCell 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 proceduresFor 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 incompatibilitySupervision of cell processingQuality assurance testingReport 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.
66 The Unprocessed Stem Cells CPT editorial board refused our request for a code for generic quality assurance testingOnly option is for those patients to continue to bill those services under 38240, 38241, and 38242
67 CMS IssuesCMS did not approve these cell processing codes and the code for unrelated donor search and organ acquisition and 38204sThese codes can be used to bill these services to non-governmental payersCMS has always had difficulty paying for organ acquisition costsCMS 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 IssuesWith the new codes we probably are better off with the non-governmental payersWith CMS, we are no worse offWork on these codes brought increased scrutiny to all apheresis and BMT related costThese 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
70 Critical CareCritical care can billed for service rendered for patient not in MICUAdvantage 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 CareCritical 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 CareCritical 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
74 Future Concerns No one is totally satisfied with the results Billing these new codes will require more time and effortBilling is moving to electronic transmittal of data. Each item in bill needs either a CPT code or HSPCS level II codeBilling 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 ConcernsThe 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 staffTheir ongoing labors for financial issues have not received the national accolades they deserve