Extracorporeal Photopheresis for BOS Now Covered

The Centers for Medicare & Medicaid Services (CMS) recently revised the National Coverage Determination (NCD) for Extracorporeal Photopheresis (110.4) to add coverage for the treatment of bronchiolitis obliterans syndrome (BOS) following lung allograft transplantation. Medicare coverage is effective for services rendered on or after April 30, 2012 when provided under a clinical research study approved by April 30, 2014.

Chronic rejection, or BOS, is the leading cause of death following the first year of lung transplantation, according to “A Review of Bronchiolitis Obliterans Syndrome and Therapeutic Strategies,” by Don Hayes, published in the Journal of Cardiothoracic Surgery.

Extracorporeal photopheresis is a “second-line” treatment for a variety of oncological and autoimmune disorders. Performed in a hospital, outpatient hospital, or critical access hospital (CAH) setting, a patient’s white blood cells are exposed to the drug 8-methoxypsoralen (8-MOP), and then to ultraviolet A (UVA) light. The treated white blood cells are re-infused into the patient, causing a series of cascading reactions that activate the immune system. The patient’s immune system is then better equipped to fend off illness.

Contractors will reimburse hospital outpatient and physician claims for CPT® code 36522 Photopheresis, extracorporeal along with one of the following ICD-9-CM diagnosis codes:

996.84 Complications of transplanted lung

491.9 Unspecified chronic bronchitis

491.20 Obstructive chronic bronchitis without exacerbation

491.21 Obstructive chronic bronchitis with (acute) exacerbation

496 Chronic airway obstruction, not elsewhere classified

In addition to the requirement for treatment to be conducted under an approved clinical research study, claims for extracorporeal photopheresis for BOS must include:

  • Diagnosis code V70.7 Examination of participant in clinical trial (secondary diagnosis)
  • Condition code 30 (Part A only)
  • Clinical trial modifier Q0 Investigational clinical service provided in a clinical research study that is an approved research study
  • Value code D4 with an eight-digit clinical trial number (optional) (fiscal intermediaries only)

Refer to Medicare Claims Processing Manual, pub. 100-04, chapter 32, section 190 for a list of additional ICD-9-CM/ICD-10 codes applicable for extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation when provided under a clinical research study.

Contractors are not retroactively adjusting claims, but may adjust qualifying claims brought to their attention.

Source: CMS transmittal 143, change request (CR) 7806, issued May 18, 2012.


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