Pathology/Lab Coding Alert

Pathologists and laboratories specializing in hematology may work closely with oncologists in the treatment of various blood and lymphoid neoplasms such as acute leukemia (208.00 ) or non-Hodgkins lymphoma (202.80). Following high-dose chemotherapy, patients may be treated using stem cell transplantation. To ensure proper reimbursement, pathologists and labs involved with the various steps of stem cell collection, storage, and transplantation need to know the coding options so they can make the appropriate choices.

Stem cells are parent blood cells, which produce an ongoing supply of identical stem cells, as well as a supply of differentiated, mature blood cells of all types, including red blood cells, various types of white blood cells and platelets. They are found in a large concentration in the bone marrow and in a much lower concentration in the blood. A patient may receive his or her own stem cells (autologous transplant), or stem cells taken from a suitable, matching donor (allogenic transplant), either of which can be collected, or harvested, from blood or bone marrow and stored until needed for transplantation. Allogenic stem-cell transplantation provides the opportunity for treatment to patients who might be unsuitable for autologous transplant because of tumor involvement in the bone marrow or previous irradiation that compromised stem cell production. The goal of stem cell transplantation is to counter a loss of blood cells by transfusing parent cells into the patient to rebuild the blood supply, after high-dose chemotherapy destroys malignant cells.

Stem Cell Harvesting, Storage and Transplantation

We specialize in autologous peripheral stem cell transplantation because of the ease of collection, faster recovery and long-term disease benefits, reports Dipnarine Maharaj, MD, director of the Bone Marrow Stem Cell Transplant Institute at Bethesda, in Boynton Beach, Fla., and a fellow of the Royal College of Pathologists of the United Kingdom.

The patients oncologist and transplant physician (often a hematologist) will coordinate care carefully while the patient receives chemotherapy, states Maharaj. The patient typically has an intravenous catheter placed codes 36488-36533, depending on circumstances such as which vein is used and the patients age to facilitate the frequent blood analyses and treatment procedures that will be taking place, he continues.

Harvesting: Before stem cell collection, the patient will receive stem cell growth- stimulating factors, either through the catheter (if one is present); an IV push, 90784 (therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous); or subcutaneous injection, 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Harvesting can take place as soon as the stem cell count in the peripheral blood is high enough, and white blood cell counts and marrow recovery are favorable, according to Maharaj.

Cytapheresis is the process of collecting blood, separating the stem cells by centrifugation or filtration, and immediately returning the remaining cells to the patient. The procedure may be done in an in- or outpatient setting. We perform outpatient services, and on average, the patient will come in for three apheresis sessions to collect sufficient stem cells for transplantation, reports Maharaj. The number of required harvests varies with the type of cancer and individual blood characteristics.

Each stem-cell cytapheresis session is reported using code 38231 (blood-derived peripheral stem cell harvesting for transplantation, per collection), reports Kevin Bundy, BB, MT, SBB (ASCP), CLS (NCA), supervisor of the Progenitor Cell Laboratory at the Mayo Clinic in Rochester, Minn. Use 38231 instead of the more general code for apheresis, 36520 (therapeutic apheresis; plasma and/or cell exchange), because 38231 more specifically describes the service rendered. Also note that, according to CPT Assistant, April 1996, blood collection is an inherent component of stem cell apheresis, so it would be inappropriate to report code 99195 (phlebotomy; therapeutic [separate procedure]) in addition to 38231.

In some cases, the stem cells may be further processed, for example, to reduce T-cells for the prevention of graft/host disease, explains Bundy. Such processing would be reported using code 86915 (bone marrow or peripheral stem cell harvest, modification or treatment to eliminate type[s] [e.g., T-cells, metastatic carcinoma]).

Stem cells also may be collected from the bone marrow itself rather than from the peripheral blood. The procedure involves removal of bone marrow through a biopsy needle inserted in the iliac crest. The proper code for this type of bone marrow harvesting is 38230 (bone marrow harvesting for transplantation), reports Bundy. It would not be appropriate to code 85095 (bone marrow; aspiration only), which describes the sampling of bone marrow cells for diagnostic purposes. Again, code 86915 would be reported to describe any processing of bone marrow (e.g., stem cell removal, volume reduction) before transplantation.

Storage: Following each cytapheresis, stem cells are cryopreserved until time for transplantation, Maharaj explains. Stem cells may survive for many years if they are protected from freezing injury. A cryoprotectant such as dimethyl sulfoxide (DMSO) is used to control the rate of cooling. The cells are stored in a liquid nitrogen freezer with careful temperature monitoring.

To code the cryopreservation and storage of peripheral blood stem cells, use code 88240 (cryopreservation, freezing and storage of cells, each cell line). Notes following the code definitions for bone marrow or stem cell transplantation services (38230-38241) direct coders to 88240 for cryopreservation of blood-derived stem cells.

In the case of stem cells derived from bone marrow, the material usually is not frozen before infusion. Typically, bone marrow is transplanted fresh, rather than being placed in frozen storage for use at a later time, reports Bundy.

Transplantation: After a sufficient quantity of stem cells have been collected and preserved, the patient receives high-dose chemotherapy to quickly eradicate cancer cells, says Maharaj. Under the coordinated care of the transplant team, protocols are used to minimize side effects (infection, nausea, etc.) and monitor the patients for the early treatment of complications associated with marrow-ablative chemotherapy and transplant.

Before transplantation, the preserved stem cells are thawed, tested and prepared for infusion. This may involve coding for any of a number of services. For example, thawing of frozen blood derived stem cells is reported with code 88241 (thawing and expansion of frozen cells, each aliquot), says Bundy. Testing for viability, the presence of bacterial contaminants, and genetic matching may be carried out also, and should be coded depending on the services provided (e.g., compatibility studies [86812-86822]).

Typically, the transplant is accomplished with one or more infusions, similar to the administration of blood platelets. According to Bundy, Two codes are available to describe this procedure, per infusion, depending on the source of the stem cells. Code 38241 describes an autologous transplant from either the patients own blood or bone marrow. Code 38240 describes an allogenic transplant of either bone marrow or blood-derived stem cells. Additional anti-graft rejection drugs may be administered for allogenic transplants, and may be reported using code 90784 (therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous), or other appropriate drug-administration code (report the appropriate HCPCS Level II code for the drug).

Following the transplant, daily patient monitoring continues for about 10 to 12 days. Over approximately two weeks, the patients immune system and blood functions should recover. During this, or any phase of patient treatment, individual tests that are ordered to monitor patient condition (e.g., complete blood count [CBC] 85022-85025) should be coded accordingly, concludes Bundy.