Practice Management Alert

Question: A patient covered by Palmetto GBA presented for his first dose in the treatment regimen. He has been diagnosed with minimally symptomatic castrate-resistant (hormone refractory) prostate cancer that has metastasized to the intrathoracic lymph nodes and meets the other requirements for coverage. Staff administered Provenge over the course of 61 minutes. How should I bill or this service?

South Carolina Subscriber

Answer: Per payer policy, you should bill:

• Q2043, Sipuleucel- T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion
• 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• 185, Malignant neoplasm of prostate
• 196.1, Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes.

Provenge reimbursement and billing policies are very specific, so reading the national and local policies in full is important. For instance, Provenge has both primary and secondary diagnosis coding requirements for on-label use. If you leave off one of the required codes, you can expect reimbursement issues.

Good practice: You will want to check what the manufacturer says against payer policies. You can search your payer's site, or the Provenge reimbursement website, which offers links to state-specific coverage information, and to the Medicare NCD [National Coverage Determination] from their website.

To see the J1 Palmetto GBA policy in full, go to www.palmettogba.com/medicare. In the search box, choose J1 Part B and enter the article title: "New HCPCS Code for Provenge." The results page will show the link for that article.