Pulmonology Coding Alert

Photodynamic therapy (PDT) is a nonsurgical procedure gaining acceptance with pulmonologists across the country for treating patients with lung cancer. This treatment is a three-step process. First, the patient is given an injection of a photosentizing agent. Then, after an appropriate waiting period, the pulmonologist performs a bronchoscopy, and in the final step, a laser is used to remove or destroy the cancerous cells.

The key to receiving full and prompt reimbursement for this procedure from Medicare and other carriers is to make sure each step is coded correctly. To achieve this, two add-on codes, 96570-96571, were created for a special photodynamic therapy subsection in the CPT 2001 manual. According to Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C. Prior to these additions, there were no accurate codes available for this procedure; consequently, practices were left to use unlisted codes and submit claims in hard copy with the appropriate documentation. Given the burden of paper claims, coders have welcomed these two codes.

The First Step: The Intravenous Injection

A patient presents to the pulmonologists office where he receives an intravenous injection of a photoactive drug. This first step is reported using 90784 (therapeutic prophylactic or diagnostic injection [specify material injected]; intravenous), with the drug code J3490.

According to Peter Tanaka, CPC, vice president of data development at Unicore Medical, a company that publishes ICD-9 coding books and software in Montgomery, Ala., the physician, while he supervises the treatment, does not have to administer the medication; a nurse can do it. This step is coded as incident to because it is performed as though the physician has administered it and it meets these general guidelines accepted by Medicare in this situation:

1. The physician has established the treatment plan for this particular patient; and

2. The nurse is acting under the direct supervision of the doctor, who must be within the office space although not necessarily in the room.

Note: Availability by telephone does not meet this requirement.

The Second Step: Bronchoscopy

About two days later, the patient returns to the doctors office. This waiting period has given the photosensitizing agent time to leave the healthy cells but to remain in the cancerous ones. The fiberoptic that will destroy the cancerous cells is now directed through a bronchoscope into the patients lung. This procedure is reported using 31641 (bronchoscopy; with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser).

The Third Step: Laser Use

Finally, the laser is activated, and the light source applied to the patients cancerous cells. This is reported using the two new add-on codes 96570 and 96571. [...]