Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 16, 2004 PDF

Don't treat draft local coverage decisions as gospel
 
If you're using monoclonal antibodies Bexxar and Zevalin in a diagnostic study aimed at determining the location of a tumor or the biodistribution of the agent, you could be in for some confusion.
 
CPT Codes 2004 introduced a new code, 78804, for radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agents requiring more than two days' imaging. And, as of April 1, Medicare phased out the old codes G0273 and G0274, for studies and therapeutic uses involving radiopharmaceutical agents.
 
But at least one carrier hasn't caught up to reality yet. In a draft LCD entitled "Radiopharmaceuticals: Monoclonal Antibodies, Diagnostic," Noridian Administrative Services still insists that 78800-78804 should only be used for diagnostic tests involving Arcitumomab, ProstaScint, Verluma and OncoScint, and you can use 78800 and 78803 for scans involving MyoScint. But when it comes to Bexxar and Zevalin, Noridian insists physicians should bill G0273 instead. (The comment period for this LCD just ended on April 15.)
 
Other carriers, including Wisconsin Physician Services, HGSA and Cigna, encourage physicians to use 78804 with Bexxar and Zevalin in their coverage policies. They say you should use this code along with A9522 for Zevalin or A4641 for Bexxar. You can only bill this code once per lifetime, according to WPS. And you should use new code 79403 (Radiopharmaceutical therapy, radiolabled monoclonal antibody by intravenous infusion) for therapeutic uses, they say. Similarly, Cardinal Health Systems issued coding guidance for Zevalin in which it encouraged providers to use 78804 for tests.
 
Noridian probably will correct its instructions in the final policy, predict experts. "Since it's a draft, I'm sure they're getting lots of comments," says consultant Cindy Parman with Coding Strategies in Powder Springs, Ga.
 
The moral of the story: "Don't go by anything you see in a draft," says Parman. "It's never final until it really gets cast in concrete." She suspects the purpose of the new Noridian LCD was to reinforce that providers should use the A-codes (such as A4641 and A9522) for these drugs, instead of the C-codes, which are hospital only.