Anesthesia Coding Alert

Question: I have read that some Medicare contractors allow reimbursement for extracorporeal immunoad-sorption therapy for treating rheumatoid arthritis. What is the correct code for reporting the procedure? New York Subscriber Answer: In a decision memorandum dated April 27, 2000, the Centers for Medicare and Medicaid Services (CMS) determined that extracorporeal immunoadsorption using protein A columns is a reasonable and necessary treatment for rheumatoid arthritis (RA). Previously, the protein A column therapy was covered only for idiopathic thrombocytopenic purpora (ITP).

According to the LMRP for Empire Medical Services, Medicare carrier for New York, code 36521 (Therapeutic apheresis; with extracorporeal affinity column adsorption and plasma reinfusion) should be used to report these procedures after Jan. 1, 2001. However, extracorporeal immunoadsorption using protein A columns is considered medically necessary and reasonable for RA only when the following conditions apply: The patient has severe RA. The disease is active (> 5 swollen joints, > 20 tender joints, and morning stiffness > 60 minutes). The patient has failed an adequate course of a minimum of three disease-modifying anti-rheumatic drugs (DMARDs). Failure does not include intolerance to the medication. ICD-9-CM codes related to RA that support medical necessity include:
714.0 Rheumatoid arthritis 714.1 Felty's syndrome 714.2 Other rheumatoid arthritis with visceral or systemic involvement 714.30 Polyarticular juvenile rheumatoid arthritis, chronic or unspecified 714.31 Polyarticular juvenile rheumatoid arthritis, acute 714.32 Pauciarticular juvenile rheumatoid arthritis 714.33 Monoarticular juvenile rheumatoid arthritis. Empire Medical's LMRP also lists a number of limitations, including: Documentation of disease activity is required for more than eight apheresis treatments per patient in any six-month period. The standard payment adjustment for multiple surgical procedures applies. There is a statutory payment restriction for assistants at surgery for this code; therefore, assistant at surgery may not be paid. Payable places of services are inpatient hospital (21) and outpatient hospital (22).

Most, but not all, Medicare contractors cover this service. It is best to ask your local Medicare and private carriers for their guidelines.