Pathology/Lab Coding Alert

Avoid bundling pitfalls that sabotage reimbursement.

Billing for a pathologist with a hematology specialization means you need to understand the many steps involved in harvesting and processing stem cells for transplantation. If you don't, billing errors and omissions could cost your lab significant pay.

Focus: Let our experts show you what you need to do to ensure you don't leave money on the table for services to extract, process, and preserve stem cells for transplant.

Terminology: Billing these procedures requires you to know the following specialized medical terms:

• Stem cells: Also called progenitor cells, stem cells produce an ongoing supply of identical stem cells and all types of differentiated, mature blood cells (erythrocytes, or red blood cells; leukocytes, or white blood cells; and platelets). Bone marrow contains a large concentration of stem cells, but peripheral blood also contains stem cells in lower concentration.
• Allogeneic: Describes cells or tissue obtained from a different individual than the transplant recipient.
• Autologous: Describes cells or tissue obtained from the same individual as the transplant recipient.

Specify Stem Cell Harvest

The pathologist/hematologist may extract stem cells from either a "self" (autologous) or "other" (allogeneic) donor, and either from bone marrow or peripheral blood. Those distinctions mean that you have several codes to choose from to describe this process.

For stem-cell harvesting from bone marrow, use one of the following two CPT^® codes:

• 38230 (Bone marrow harvesting for transplantation; allogeneic)
• 38232 (... autologous).

For stem-cell harvesting from peripheral blood, use one of the following two CPT^® codes:

• 38205 (Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic)
• 38206 (... autologous).

Source is key: You can see that identifying the source as bone marrow or blood is the first step to getting to the proper code family. But once you're in the right code family, you have to distinguish allogeneic or autologous to drill down to the proper code.

Remember, autologous is "from the patient's own body," says Kelly Loya, CPhT, CPC-I, CHC, CRMA, a managing director at Pinnacle Enterprise Risk Consulting Services, LLC.

Don't Confuse Procedure Codes

Similar bone marrow codes exist which can cause misdirection. Bone marrow codes that involve aspirations or diagnostic sampling look like harvesting codes, especially in their descriptions, but these are altogether different procedures. Be careful not to confuse a bone marrow stem cell harvest with operations represented by codes like 38220 (Bone marrow; aspiration only) and 38221 (... biopsy, needle or trocar).

Blood cell codes can also be tricky. Some codes mention the harvesting technique known as apheresis, and you can easily substitute these incorrect codes with the proper harvesting code. These other apheresis codes, however, are not sufficient in representing the total workload involved in a harvesting procedure. Keep a look out for codes that mention apheresis, like 36511 (Therapeutic apheresis; for white blood cells), 36512 (Therapeutic apheresis; for red blood cells), and 36513 (Therapeutic apheresis; for platelets) and take care not to confuse them with the blood-cell harvesting codes 38205 and 38206.

Keep Track of Blood Cell Harvesting Sessions

Although stem-cell harvesting from bone marrow may be a one-time shot, the clinician typically needs to accumulate stem cells from multiple sessions when harvesting from blood. The blood-harvesting process described by 38205 and 38206 involves extracting donor blood, separating and collecting stem cells, and re-infusing remaining blood components back into the donor.

Per session: You'll notice that codes 38205 and 38206 specify "per collection" in the descriptor, which means that you should report the appropriate code each time your pathologist carries out the procedure.

Bundling concerns: Many of the stem-cell harvesting codes are subject to bundling edits that you need to know. For instance, "If you look at the current National Correct Coding Initiative (CCI), 32806 is mutually exclusive to 32805. Therefore, you cannot bill these codes together in any circumstance." says Kristen Taylor, CPC, CHC, a managing director at Pinnacle Enterprise Risk Consulting Services, LLC.

Similarly, CCI bundles the 38205-38206 codes with the 38230-38232 codes, with no ability to override the edit pairs with a modifier such as 59 (Distinct procedural service).

Here's why: Based on patient and donor details, the treating physician and hematologist/pathologist will determine whether to perform an allogeneic or autologous transplant, and whether to harvest cells from bone marrow or peripheral blood. Those are either/or decisions, and you would not expect to see services that mix the source and type of harvesting.

Learn Harvest Processing Codes

Following the harvesting procedure, clinicians will process the harvested cells in a variety of procedures. These steps may include work to either concentrate, or deplete or remove certain cell types. Choose one or more of the following codes that accurately describe any of these processes performed:

• 38210 (Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion)
• 38211 (... tumor cell depletion)
• 38212 (... red blood cell removal)
• 38213 ( ... platelet depletion)
• 38214 (... plasma (volume) depletion)
• 38215 (...cell concentration in plasma, mononuclear, or buffy coat layer).

Caution: CPT^® 2018 introduces a new Category III code that includes autologous harvesting and white blood cell concentration as part of a protein injection treatment (0481T, Injections, autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation when performed). Don't use any of the 38210 family of codes instead of, or in addition to, 0481T for this new procedure.

Freezing: Harvesting stem cells for transplant also involves freezing, storing, and thawing the gathered elements. If you forget to code this preservation process, you're leaving money on the table. Instead, you can know and use the following codes to gather appropriate pay for the services:

• 38207 (Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage)
• 38208 (... thawing of previously frozen harvest, without washing, per donor)
• 38209 (... thawing of previously frozen harvest, with washing, per donor).

Tip: Similar codes in the pathology section describe cell-line freezing, storage, and thawing, as follows:

• 88240 (Cryopreservation, freezing and storage of cells, each cell line)
• 88241 (Thawing and expansion of frozen cells, each aliquot).

These codes describe cell processing for cytogenetic studies, and you should not use them with, or in place of, 38207-38209 for to describe processing stem cells for transplant.