Oncology & Hematology Coding Alert

If your claims fell victim to these erroneous bundles, now's the time to resubmit.

Staying up to date on Provenge coding rules certainly keeps you on your toes.

First, Medicare said you couldn't report an administration code with Provenge code Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion). Then, even after CMS changed that rule, a Correct Coding Initiative (CCI) edit bundled certain administration codes into Q2043.

Good news: Your claims for this prostate cancer therapy should have smoother sailing now that CCI has implemented much needed edit deletions for physicians.

Take Advantage of Retroactive Deletion

CCI version 18.1, effective April 1, 2012, deletes edits bundling the following codes into Q2043:

• 96360, Intravenous infusion, hydration; initial, 31 minutes to 1 hour
• 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• 96372, 96374-+96376, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug) ...

Key: The deletions are retroactive to July 1, 2011 -- the date the edits originally became effective, according to Frank Cohen, principal and senior analyst for The Frank Cohen Group, in his NCCI 18.1 Update. The retroactive deletion means Medicare and other payers who apply CCI edits must reimburse claims as if these edits never existed.

Action point: Check the Provenge claims you submitted with July to March dates of service. If Medicare denied one of the bulleted codes above because of the edits, you may resubmit the claim for payment. The most important deletion is the one involving 96365 because it represents the one-hour of infusion time Provenge typically requires.

In fact, several Medicare Administrative Contractors (MACs) have posted the following information: "CMS has instructed Medicare contractors to adjust claims for dates of service on and after Fri July 1 containing CPT® code 96365 that were denied and not paid due to the bundle editing, when brought to their attention.

Providers may, beginning Sun Apr 1, request contractors to adjust claims for administration of PROVENGE® that were denied for this reason." (As an example, see the announcement posted by J5 Part B MAC WPS Medicare at http://wpsmedicare.com/j5macpartb/publications/news/cms_news/2012-0319-info-provenge.shtml.)

Be sure you catch that you must be the one to initiate reprocessing. There won't be an automatic adjustment, says Lisa S. Martin, CPC, CIMC, CPC-I, chargemaster specialist for OSF Healthcare System in Peoria, Ill.

Review Current Transmittal's Admin Coding Rule

The edit deletions raise two issues that are key to clean Provenge claims. The first issue is that Medicare policy does allow reporting a code for administration in addition to Q2043.

Consider this timeline of Provenge-related transmittals and what they reveal about reporting admin codes:

• July 8, 2011: In Transmittal 2254 CMS announced that Q2043 included all related services. The transmittal specifically listed administration as not separately billable. So at that point, the now-deleted edits made sense.
• Nov. 2, 2011: CMS rescinded Transmittal 2254 and replaced it with Transmittal 2239, effective June 30, 2011. Transmittal 2239 stated, "Q2043 is all-inclusive and represents all routine costs except for its cost of administration." CMS also told payers:

"Please note the administration of PROVENGE® can be billed separately."

• Jan. 6, 2012: CMS rescinded Transmittal 2239 and replaced it with Transmittal 2380, also effective June 30, 2011. This current transmittal again makes it clear that payers should reimburse for administration in addition to Q2043 (www.cms.gov/transmittals/downloads/R2380CP.pdf).

Prevent a $66 Mistake With This Strategy

The second issue raised by the edit deletions is whether they indicate that Medicare expects you to use 96365 as the admin code for Provenge.

The reality is you need to verify whether your payer wants you to use 96365 or 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug).

Why 96413? Many experts believe the significant risks involved in administering Provenge mean that the "chemotherapy" infusion codes would be more appropriate. (Remember that CPT® states the chemotherapy admin codes aren't limited to chemotherapy infusions. The codes also apply to highly complex infusions of other biological response modifiers.) Additionally, CCI doesn't bundle 96413 into Q2043, so there's no edit preventing you from reporting the two together.

Smart move: Check with the individual payer, says Martin. The Provenge website offers the same advice, instructing providers to verify with their respective MACs or commercial payers whether they have established specific coding requirements, she says.

For example, Wellmark Blue Cross and Blue Shield and Noridian Medicare both instruct their providers to report 96365, as these policies show:

• www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/_Cellular_Immunotherapy_Prostate_CancerPrinterFriendly.aspx
• www.noridianmedicare.com/provider/updates/docs/sipuleucel-T_coverage_criteria_for_prostate_cancer_clarification.pdf%3f.

In contrast, J12 MAC Novitas indicates it expects to see 96413 reported for administration (www.novitas-solutions.com/bulletins/all/news-02172011.html).

Fee impact: Medicare's national rate for 96365 is $72.50 in 2012. Code 96413's 2012 rate is $138.53. That's a difference of about $66. Confirm that you're using the proper code for your payer to avoid both under- and over-payments.

Resources: You'll find additional Provenge coding information in MLN Matters 7431, effective June 30, 2011: www.cms.gov/MLNMattersArticles/downloads/MM7431.pdf. The current CCI edits are available for download at www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp.