Part B Insider (Multispecialty) Coding Alert

Published on Fri Apr 27, 2012 PDF

Forget even one step of this process and you could sacrifice reimbursement.

When your physician makes use of photodynamic therapy (PDT) to treat a patient with cancer, you need to report all key components of the therapy that includes infusion, bronchoscopy and the laser activation. Read on for some refresher tips to tackle photodynamic therapy reporting with confidence.

Capture All Aspects of the Infusion

The first step to photodynamic therapy is the intravenous infusion of Photofrin (Porfimer), which could be performed by your physician or by a nurse under the supervision of your physician. "If performed in the hospital, no charge can be made. If performed in the office, a charge can be made even though performed by a nurse since she will be supervised by the physician," says Alan L. Plummer, MD, Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta.

"The infusion of Photofrin should take about 10-15 minutes," says Plummer. "If the infusion lasts less than 30 minutes, use code 96374 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; intravenous push, single or initial substance/drug)," he advises. "If the infusion lasts over 30 minutes, use 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour)."

In addition to the infusion, you will need to report the J code for Photofrin. You will report this with J9600 (Injection, porfimer sodium, 75 mg).

Note Timelines for Next Procedure

After the infusion of Photofrin, the patient returns to your physician's office after a period of 48 hours. This time gap is provided to facilitate selective absorption of the Photofrin by the cancerous cells so that your physician can clearly identify it to destroy it. Your physician will undertake a bronchoscopy to identify the areas that need to be treated with the laser to destroy the cancerous cells. As this procedure is undertaken to destroy the tumor using laser therapy, you have to report the procedure with 31641 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by any method other than excision [e.g., laser therapy, cryotherapy]).

Use Add-on Codes for Laser Activation

Your physician will use a laser light source to activate the Photofrin and destroy the tumor cells. You have to report this procedure in addition to the bronchoscopy. Use appropriate add-on codes depending on the documented time your physician uses the laser. "Code +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) is a ZZZ code (timed code) and should be used for sessions lasting 23-37 minutes," says Plummer. "For activations lasting 38-52 minutes, use +96570 and +96571 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; each additional 15 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) (another ZZZ code) for each subsequent 15 minutes of photodynamic therapy."

Example: Use this scenario, provided by Plummer, to guide your coding:

A 66 year old patient with bronchogenic carcinoma undergoes photodynamic therapy via bronchoscopy 48 hours after receiving a 15 minute IV infusion of Photofrin. The photodynamic therapy takes 55 minutes. The photodynamic therapy should be coded 96570, 96571x2 in addition to 31641. The ICD-9-CM code would be 162.9 for bronchogenic carcinoma. The infusion of Photofrin would be coded 96374 on the earlier day of the infusion along with 162.9.

Note: If your physician performs the laser activation for less than 23 minutes after initiation, then you need to append modifier 52 (Reduced services) to 96570.

Apply Subsequent Add-on Codes for Other Areas

If during the procedure, your physician finds a previously undiagnosed tumor and decides to use the laser to destroy it, you will have to report the additional procedure. "If other areas of the tumor are found, treat the area and add up the time for the total session using 96570 for the first 30 minutes and 96571 for each subsequent 15 minutes," says Plummer. Keep in mind that you can bill the bronchoscopy only once for the entire procedure.

Example: Your physician treats a 60-year-old female patient for cancer of the right bronchus with PDT. He uses the laser for one hour to ablate the tumor. But, as your physician withdraws the bronchoscope, he observes another tumor in the left bronchus and decides to use the laser to ablate it. This procedure takes another 30 minutes to complete. In this scenario, you report 31641 for the bronchoscopy, +96570 for the first 30 minutes of laser activation and +96571 x 4 for the subsequent increments of laser activation.