Part B Insider (Multispecialty) Coding Alert

Published on Wed Nov 02, 2011 PDF

Include proper primary and secondary diagnosis codes to ensure payment.

If your urologist performs a new treatment for asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) carcinoma of the prostate using the drug Provenge or Sipuleucel-T, take note of a new HCPCS code for 2012.

Get to Know the Procedure

Medicare allows a patient one treatment with Provenge in their lifetime, which includes three separate infusions within a two week period, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York at Stony Brook.

"Blood is taken from the patient and exposed to prostate cancer cells, sensitizing the patient's white blood cells to attack the cancer cells when reinfused into the patient," Ferragamo explains. "This also stimulates a recruitment of additional white blood cells to destroy the tumor. Provenge is the first in a new class of therapy that is designed to activate a patient's own antigen-presenting cells to stimulate an immune response against prostate cancer. "

Report the New Code 3 Times For Full Treatment

The 2012 code for this procedure is Q2043 (Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion). This code represents the anti-neoplastic treatment for this particular type of tumor.

Note that the code descriptor states "per infusion," meaning if the patient receives three infusions during the two-week treatment period, you should report Q2043 three separate times. "You bill this once for each infusion, and Medicare will reimburse you $32,000 per infusion," Ferragamo says. "The purchased price for the drug is about $30,189 per treatment. Medicare will reimburse this cost plus a six percent increase/profit."

Don't miss: When you report Q2043 for this cancer treatment, remember that this code includes all other preparatory procedures, such as the collection of cells from the patient, the preparation and transportation of the cells to a specialized lab, and the infusion itself.

Support Claim With Proper Diagnostic Codes

When reporting Q2043, the diagnosis codes must include 185 (Malignant neoplasm of prostate) as the primary diagnosis and at least one metastatic diagnostic code as the secondary diagnosis, Ferragamo says. Possible secondary diagnostic codes include the following:

• 196.1 -- Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
• 196.2 -- ...intra-abdominal lymph nodes
• 196.5 -- ... lymph nodes of inguinal region and lower limb
• 196.6 -- ... intrapelvic lymph nodes
• 196.8 -- ... lymph nodes of multiple sites
• 197.0 -- Secondary malignant neoplasm of lung
• 198.1 -- ... other urinary organs
• 198.5 -- ... bone and bone marrow
• 198.7 -- ... adrenal gland
• 198.82 -- ... genital organs.