Coding CAR-T: Case Scenarios
Recently established coverage of the revolutionary cancer therapy Chimeric Antigen Receptor T-cell (CAR T-cell) provides Medicare patients with access to this cutting-edge treatment. The article Innovative CAR T-Cell Cancer Therapy Now Available to Medicare Beneficiaries breaks down Gilead Sciences’ Yescarta (axicabtagene ciloleucel) for acute lymphoblastic leukemia and Novartis’ Kymriah (tisagenlecleucel), approved for non-Hodgkin lymphoma and how this decision will impact Medicare patients.
An overview of CAR-T coding was provided in the article Coding CAR T: Cancer Treatment Revolutionized. This article supplements that information and provides examples to aid coders in understanding proper code assignment for the procedures involved in the provision of CAR T-cell therapy.
Yescarta is coded with HCPCS Level II code Q2041. Yescarta’s sole challenger, Kymriah (tisagenlecleucel), is coded with Q2042. When the CAR T-cell infusion is administered at an inpatient facility, assign one of the following ICD-10-PCS codes:
The Centers for Medicare & Medicaid Services (CMS) advises, “For claims submitted on or after August 7, 2019, hospitals may report for Medicare Advantage Beneficiaries temporarily being paid under Fee-For-Service Medicare the CAR T-cell-related revenue codes 087X (Cell/Gene Therapy) and 089X (Pharmacy) established by the National Uniform Billing Committee (NUBC).” When billing charges separately for tracking these services when given in a hospital outpatient department (HOPD), providers must submit the following HCPCS Level II codes:
- 0537T Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR T-cells, per day with revenue code 0871
- 0538T Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (e.g. cryopreservation, storage) with revenue code 0872
- 0539T Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR T-cells for administration with revenue code 0873
Medicare pays for the administration of CAR T-cells in the hospital outpatient setting separately under CPT Category III code 0540T Chimeric antigen receptor T-cell (CAR-T) therapy; CAR T-cell administration, autologous with revenue code 0874. Medicare includes the payment for the various steps required to collect and prepare CAR-T in the payment for the biological. You may choose to include the charges for these various steps in the claim submitted for the biological, or report these charges separately for tracking purposes.
Do not report the same charge(s) twice. Providers should choose one of the options listed above. You may not include charges for pre-infusion steps in both the drug revenue code (0891) and separately listed for the pre-infusion revenue codes (0871, 0872, and 0873).
Let’s apply these codes to some clinical scenarios for further clarification on how to report items and services related to CAR-T.
Scenario 1: CAR-T Dosing and Preparation Services and Viable T-cells Administered in Hospital Outpatient Setting:
When administering the CAR-T drug in the hospital outpatient setting, report CPT® code 0540T for the administration and HCPCS Level II Q-code Q2041 or Q2042 for the drug/biological. The procedures for the steps required for the collection and preparation of the genetically modified T-cells are not paid separately under the Outpatient Prospective Payment System (OPPS). These include CPT codes 0537T for the collection and handling, 0538T for preparation and transport, and 0539T for the receipt and preparation of the biological.
You may opt to include the charges for the various steps to collect and prepare the CAR-T cells in the charge submitted for the drug or report these charges separately for tracking purposes, but Medicare will reject them on the outpatient claim. Of note, if you include the charges for collection/preparation in the charge for the CAR-T product, code the CAR-T product service on the date the CAR-T administration took place and not on the date when the cell collection took place.
Scenario 2: CAR-T Dosing and Preparation Services Administered in Hospital Outpatient Setting, but Viable T-cells Not Administered:
In instances when CAR-T preparation services are initiated or performed in the HOPD, but the CAR-T drug is not ultimately administered to the patient, the hospital may not report the drug Q-code. Q2041 and Q2042 are only applicable when administering the genetically modified T-cells in the HOPD setting. HOPDs can report codes 0537T, 0538T, and 0539T, as appropriate, and the charges associated with each code under the appropriate revenue code on the HOPD claim to allow tracking of these services. Medicare will reject these codes as they do not pay for these services separately under the OPPS.
Scenario 3: CAR-T Dosing and Preparation Services Administered in Hospital Outpatient Setting, but Viable T-cells Administered in the Hospital Inpatient Setting:
When the initiation and provision of CAR T-cell preparation services occur in the hospital outpatient setting, but the administration of the CAR T-cells occurs in the inpatient setting, the hospital cannot report the drug Q-code. These codes only apply when the T-cells administration takes place in the HOPD setting. Report the charge associated with the various steps for the collection and preparation of the CAR T-cells on the inpatient claim separately using codes 0871, 0872, and/or 0873. The other option is for the hospital to include the charges for these steps in the charge reported for the biological using revenue code 0891 ̶ Special Processed Drugs ̶ FDA (U.S. Food and Drug Administration) Approved Cell Therapy ̶ Charges for Modified cell therapy. Inpatient providers should report the date that the CAR-T administration took place, not the date of cell collection.
To review the latest example scenarios that demonstrate how to report items and services related to CAR-T in both hospital outpatient and physician office/non-hospital clinic settings, see Transmittal 10891.
To brush up on what’s new in coding this revolutionary treatment, see the article Coding CAR-T Update in the Knowledge Center blog.
Note: The National Coverage Determination (NCD) was last updated 7/2021. Now in effect is Transmittal 10891, which adds HCPCS Level II code C9076 for Lisocabtagene maraleucel (Breyanzi; effective July 1, 2021). For more information on coding CAR-T therapy, see NCD 110.24 or MLN Matters: MM12177.