Oncology & Hematology Coding Alert

Factor these RiaSTAP code changes into your summer and winter plans.

If you treat lymphoma, leukemia, immunodeficiency, or clotting problems, you could see coding changes coming your way.

CMS has posted the HCPCS Public Meeting for Drugs Agenda from May 8, 2012. The Agenda gives a summary of proposed new codes and reveals CMS's preliminary decisions. You may access the Agenda from the Related Links list at the bottom of this site: www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCSPublicMeetings.html.

Remember: The Agenda makes it clear that these are preliminary decisions. Final decisions will be announced in November. The one exception is a RiaSTAP coding change effective July 1, described in the last section.

Expect Specific Adcetris Option

You may see a new code for Adcetris in 2013: Jxxxx (Injection, brentuximab vedotin, 1 mg).

Use: According to the requester, physicians may order Adcetris to treat Hodgkin lymphoma "after failure of autologous stem cell transplant or after failure of at least two prior multi-agent chemotherapy regimens in patients not eligible for transplant." Adcetris also can treat "systemic anaplastic large cell lymphoma (sALCL) after failure of at least one prior multi-agent chemotherapy regimen."

Applicable ICD-9-CM codes may include 201.xx (Hodgkin's disease) and 200.6x (Anaplastic large cell lymphoma).

Typically, you'll see a dosage of 1.8 mg/kg supplied from a 50 mg, single-use vial. The usual regimen involves treatment by 30-minute IV infusion every three weeks for up to 16 cycles.

Erwinaze to Get Its Own Code

CMS noted a preliminary decision to adopt Jxxxx (Injection, asparaginase [Erwinaze], 1,000 IU) for asparaginase sold under the name Erwinaze. In light of this change, there's a plan to revise the definition of existing code J9020 from "Injection, asparaginase, 10,000 units" to "Injection, asparaginase, 10,000 units, not otherwise specified."

Drug difference: Erwinaze is derived from Erwinia chryansthemi, so it may be appropriate for patients with a hypersensitivity to E.coli-derived L-asparaginase, the requester stated. Physicians may order Erwinaze "as part of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia (ALL)." Relevant diagnosis codes may fall in the range of 204.0x (Lymphoid leukemia acute).

Administration is by intramuscular injection, and the patient may have multiple injections per encounter depending on the dosage ordered. Keep a careful eye on unit requirements. The proposed NOS code is per 10,000 units, and the proposed Erwinaze code is per 1,000 IU. Currently, Erwinaze vials contain 10,000 IU.

Gammagard Code May See Revision

Expect to see "intravenous" removed from the current definition of J1569 (Injection, immune globulin, [Gammagard liquid], intravenous, non-lyophilized, [e.g. liquid], 500 mg) so that it becomes J1569 (Injection, immune globulin, [Gammagard liquid], non-lyophilized, [e.g. liquid], 500 mg).

Rationale: The requester wanted a new code specific to Gammagard Liquid for subcutaneous use. CMS's preliminary decision instead revises the current code by removing the term "intravenous" so that the code can apply to the agent supply regardless of injection method.

The physician may order Gammagard to treat patients with primary immunodeficiency. Dosage will vary based on the patient's clinical response to treatment.

Watch Dates for Compliant Fibrinogen Coding

A chain of changes is in store for RiaSTAP human fibrinogen concentrate.

Confirmed: Medicare has created Q2045 (Injection, human fibrinogen concentrate, 1 mg), effective July 1, 2012. When this code becomes effective (with status C, carrier-priced), current code J1680 (Injection, human fibrinogen concentrate, 100 mg) will change to status I, meaning it is invalid for Medicare use.

In other words, starting July 1, 2012, you should report Q2045 instead of J1680 to Medicare for RiaSTAP.

Tentative: According to the HCPCS Agenda, CMS's preliminary decision is to discontinue both Q2045 and J1680 at the end of December 2012 and to establish new code Jxxxx (Injection, human fibrinogen concentrate, 1 mg) for dates of service on or after Jan. 1, 2013. (The agenda posted at publication time states "Discontinue Q2045 effective December 31, 2012," and "Discontinue J1680 effective December 21, 2012." Because the new J code is set to be effective Jan. 1, 2013, stay alert for clarification on whether the Dec. 21 discontinuation date for J1680 should read Dec. 31.)

Be sure to watch the unit differences between J1680 (per 100 mg) and the new codes Q2045 (per 1 mg) and Jxxxx (per 1 mg). The unit change is a driving factor behind creating the new codes. Here's why: After J1680 became effective, CMS issued a transmittal changing the clotting factor furnishing fee from "per IU" to "per unit" without defining "unit." The Agenda states, "As a result, the Part B MACs have applied varying interpretations to the application of the furnishing fee to RiaSTAP. Some define unit as 'per 100mg' and others as 'per mg.'" The requester's hope is that the "per mg" codes will encourage a standard definition of 1 mg for a clotting factor "unit."

Diagnosis and administration: Physicians order RiaSTAP to replace the coagulation factor needed for clotting in patients with congenital fibrinogen deficiency, according to the requester. An appropriate ICD-9-CM code could be 286.3 (Congenital deficiency of other clotting factors). Administration is intravenous with an initial dose of 70 mg/kg and additional doses based on patient requirements.