review of new cpt codes affecting bmt services

Review Of New Review Of New CPT Codes AffectingCPT Codes Affecting

BMT ServicesBMT Services

Presented by: James L. Gajewski, M.D.Presented by: James L. Gajewski, M.D.

Disclaimer: Please note that the opinions Disclaimer: Please note that the opinions expressed in this presentation are those of expressed in this presentation are those of the presenter and, as such, are intended as the presenter and, as such, are intended as guidance only. As always, final interpreta-guidance only. As always, final interpreta-tion of the requirements of any code, tion of the requirements of any code, including the acceptability of billing and including the acceptability of billing and documentation practices, rests in the documentation practices, rests in the domain of the private payer or authorities domain of the private payer or authorities of the Centers for Medicare and Medicaid of the Centers for Medicare and Medicaid Services.Services.

OverviewOverview BackgroundBackground

Review new codes and CMS issuesReview new codes and CMS issues

Critical care E&M issuesCritical care E&M issues

Future concernsFuture concerns

BackgroundBackground

AbbreviationsAbbreviations

CPT = Current Procedural TerminologyCPT = Current Procedural Terminology

RVU = Relative Value UnitsRVU = Relative Value Units

HCPCS = Healthcare Common Procedure HCPCS = Healthcare Common Procedure Coding SystemCoding System

CommitteesCommittees

CPT Editorial Panel CPT Editorial Panel

RVU-RBRVS Update Committee (RUC)RVU-RBRVS Update Committee (RUC)

Outpatient Practice Expense – Practice Outpatient Practice Expense – Practice Expense Allocation Committee (PEAC)Expense Allocation Committee (PEAC)

Coalition To Address Coding Coalition To Address Coding DeficienciesDeficiencies

Sponsor: American Society of HematologySponsor: American Society of Hematology Co-Sponsors: Co-Sponsors:

– American Society for Blood and Marrow TransplantationAmerican Society for Blood and Marrow Transplantation

– American Association of Blood BanksAmerican Association of Blood Banks

– International Society of Cellular TherapyInternational Society of Cellular Therapy

– The National Marrow Donor ProgramThe National Marrow Donor Program

– American Society of Clinical OncologistsAmerican Society of Clinical Oncologists

– American Red CrossAmerican Red Cross

– Exempt Cancer Centers CommitteeExempt Cancer Centers Committee

– Foundation for Cellular TherapiesFoundation for Cellular Therapies

New Billing RegulationsNew Billing Regulations

One price per CPT code One price per CPT code

per patient billper patient bill

Old Codes Are InadequateOld Codes Are Inadequate

ApheresisApheresis ApheresisApheresis

Plasma PheresisPlasma Pheresis

Cell ProcessingCell Processing T- and B-cell Removal T- and B-cell Removal 86915; Cross-reference to 86915; Cross-reference to 88240 and 88241 for 88240 and 88241 for cryopreservation and cryopreservation and thawingthawing

CPT editorial committee has been trying CPT editorial committee has been trying to enhance “granularity” of CPTto enhance “granularity” of CPT

Most patient bills need either HCPCS Most patient bills need either HCPCS Level I better known as CPT codesLevel I better known as CPT codes

OROR HCPCS Level II codes attached to HCPCS Level II codes attached to

services for electronic billing of servicesservices for electronic billing of services

Review Of New CodesReview Of New Codes Rationale behind requestRationale behind request

Facility related expensesFacility related expenses

Physician professional componentPhysician professional component

Documentation necessitiesDocumentation necessities

ApheresisApheresis Therapeutic apheresis: Therapeutic apheresis:

– 36511 36511 For white blood cellsFor white blood cells– 36512 36512 For red blood cellsFor red blood cells– 3651336513For plateletsFor platelets– 36514 36514 For plasma pheresisFor plasma pheresis– 36515 36515 With extracorporeal With extracorporeal

immunoadsorption and plasma reinfusionimmunoadsorption and plasma reinfusion– 36516 36516 With extracorporeal selective With extracorporeal selective

adsorption or selective filtration and plasma adsorption or selective filtration and plasma reinfusionreinfusion

ApheresisApheresisRationaleRationale

Different costs of disposables for different Different costs of disposables for different proceduresprocedures

Different types of personnel using Different types of personnel using procedures that are commonly performed on procedures that are commonly performed on emergent basisemergent basis

Different level of physician involvement for Different level of physician involvement for different proceduresdifferent procedures

ApheresisApheresisFacility Related ExpensesFacility Related Expenses

All apheresis codes are billed as facility basedAll apheresis codes are billed as facility based Each procedure has separately priced Each procedure has separately priced

disposablesdisposables Each code has the appropriate technical Each code has the appropriate technical

component to assure appropriate billingcomponent to assure appropriate billing– e.g. time for performing a white blood cell or e.g. time for performing a white blood cell or

plasma exchange may be greater than a red blood plasma exchange may be greater than a red blood cell or platelet exchangecell or platelet exchange

ApheresisApheresisFacility Related ExpensesFacility Related Expenses

For governmental payers, these procedures For governmental payers, these procedures can only be billed from hospital based can only be billed from hospital based inpatient or outpatient facilitiesinpatient or outpatient facilities

Project for future is PEAC survey for these Project for future is PEAC survey for these services so that free standing facilities can services so that free standing facilities can bill governmental payersbill governmental payers

ApheresisApheresisPhysician Professional ComponentPhysician Professional Component

Physician work effort surveys were done but Physician work effort surveys were done but RUC did not approve of the surveysRUC did not approve of the surveys

Each apheresis procedure has an RVU of 1.74Each apheresis procedure has an RVU of 1.74 The RVU for 36516 may be decreased to 1.22 The RVU for 36516 may be decreased to 1.22

in 2004in 2004

ApheresisApheresisProfessional Billing CriteriaProfessional Billing Criteria

1.1. Procedural professional fee does not Procedural professional fee does not require physician to do procedure, but require physician to do procedure, but requires physician to examine patient requires physician to examine patient during procedure and demonstrate active during procedure and demonstrate active supervision of procedure.supervision of procedure.

2.2. Physician must be available. Available Physician must be available. Available means within hospital during entire means within hospital during entire procedure. This does not mean the procedure. This does not mean the physician must remain in pheresis unit. physician must remain in pheresis unit.

ApheresisApheresisProfessional Billing CriteriaProfessional Billing Criteria

4.4. Evaluation of patients for apheresis is billable Evaluation of patients for apheresis is billable separately as long as it is done on a different day. separately as long as it is done on a different day. This is billed on consult H&P. This is billed on consult H&P.

5.5. Post-procedure follow-up is also billable separately Post-procedure follow-up is also billable separately as long as it is done on a different day, following as long as it is done on a different day, following E&M service. E&M service.

6.6. For inpatients, different physicians from same For inpatients, different physicians from same specialty may bill service on the same day. specialty may bill service on the same day. Hematologists follow acute leukemia on inpatients Hematologists follow acute leukemia on inpatients and different hematologists perform apheresis and different hematologists perform apheresis procedures. procedures.

Billing for apheresis Billing for apheresis services would be easier if services would be easier if apheresis was recognized apheresis was recognized

as a unique specialty!as a unique specialty!

Donor Search and Transplant Donor Search and Transplant Product AcquisitionProduct Acquisition

3820438204 Management of recipient Management of recipient hematopoietic progenitor cell donor search hematopoietic progenitor cell donor search and cell acquisitionand cell acquisition

Donor Search and Transplant Donor Search and Transplant Product Acquisition – 38204Product Acquisition – 38204Physician Professional ComponentPhysician Professional Component

For physician supervision of donor For physician supervision of donor search coordinators identifying an search coordinators identifying an unrelated donor and communicating with unrelated donor and communicating with donor center medical directors and the donor center medical directors and the harvesting physicians. This code is also to harvesting physicians. This code is also to be used for cord blood searches. Patient be used for cord blood searches. Patient contact is not necessary for this code to contact is not necessary for this code to be billed.be billed.

Donor Search and Transplant Donor Search and Transplant Product Acquisition – 38204Product Acquisition – 38204

Facility Related ExpensesFacility Related Expenses This donor search CPT code may not be used for This donor search CPT code may not be used for

NMDP/Cord Blood Registry donor services on NMDP/Cord Blood Registry donor services on product acquisition.product acquisition.

On patient bills, these services should either have no On patient bills, these services should either have no CPT attached or a generic CPT code such as 38999.CPT attached or a generic CPT code such as 38999.

Future task is to create HCPCS Level II codes for Future task is to create HCPCS Level II codes for these services. these services.


Facility Related ExpensesFacility Related Expenses The donor search code will usually be billed once. This The donor search code will usually be billed once. This

may be billed for successful and unsuccessful searches.may be billed for successful and unsuccessful searches.

If a search goes to BMT, the BMT fails and a new If a search goes to BMT, the BMT fails and a new search is done for a new donor, this code may be billed search is done for a new donor, this code may be billed twice.twice.

If a DLI or boost from the same donor is used, then If a DLI or boost from the same donor is used, then this code may not be billed twice. this code may not be billed twice.


Medicare chose not to recognize this Medicare chose not to recognize this code. Medicare felt the service should be code. Medicare felt the service should be valued under infusion CPT 38240.valued under infusion CPT 38240.

Appeal is underway.Appeal is underway.

Stem Cell CollectionStem Cell Collection

38205 Blood derived hematopoietic 38205 Blood derived hematopoietic progenitor cell harvest for transplantation; progenitor cell harvest for transplantation; allogeneicallogeneic

38206 Blood derived hematopoietic 38206 Blood derived hematopoietic progenitor cell harvest for transplantation; progenitor cell harvest for transplantation; autologousautologous

Stem Cell Collection – 38205 & 38206 Stem Cell Collection – 38205 & 38206 RationaleRationale

The old codes were split due to The old codes were split due to expenses for donor evaluationexpenses for donor evaluation

Stem Cell Collection – 38205 & 38206Stem Cell Collection – 38205 & 38206Facility Related ExpensesFacility Related Expenses

Both codes cover the collection Both codes cover the collection services for one day’s collection. services for one day’s collection.

Multiple day’s services require Multiple day’s services require multiple uses of this code. multiple uses of this code.

Stem Cell Collection – 38205 & 38206Stem Cell Collection – 38205 & 38206Facility Related ExpensesFacility Related Expenses

For governmental payers, i.e. Medicare or Medicaid, For governmental payers, i.e. Medicare or Medicaid, these services are facility based. these services are facility based.

They can only be billed from hospital based inpatient They can only be billed from hospital based inpatient or outpatient collection facilities. This does not apply or outpatient collection facilities. This does not apply to non-governmental payers. to non-governmental payers.

If we try to make these codes not-facility based, the If we try to make these codes not-facility based, the issue is whether nurse time can be attached to issue is whether nurse time can be attached to practice expense or must be allocated to professional practice expense or must be allocated to professional fee. This needs to be better understood before doing a fee. This needs to be better understood before doing a PEAC surveyPEAC survey

Stem Cell Collection – 38205 & 38206Stem Cell Collection – 38205 & 38206Suggested Suggested Facility Related ExpensesFacility Related Expenses

The pricing of the service may include: The pricing of the service may include:

Nurse/technician time, machine disposables, Nurse/technician time, machine disposables, machine depreciation, space utilized and all machine depreciation, space utilized and all costs associated with meeting regulatory costs associated with meeting regulatory requirements. requirements.

Stem Cell Collection – 38205 & 38206Stem Cell Collection – 38205 & 38206Physician Professional ComponentPhysician Professional Component

Physicians may bill for this procedure even if not Physicians may bill for this procedure even if not doing the procedure. RVU valuation was for physician doing the procedure. RVU valuation was for physician supervision of nurse/ technician performing the supervision of nurse/ technician performing the procedure. To bill, the physician must document procedure. To bill, the physician must document exams during procedures and supervision of staff for a exams during procedures and supervision of staff for a particular patient. Physician must remain within particular patient. Physician must remain within hospital for entirety of procedure and be immediately hospital for entirety of procedure and be immediately available. The physician does not need to be in the available. The physician does not need to be in the apheresis unit for entirety of procedure.apheresis unit for entirety of procedure.

This is a per-day physician charge for management of This is a per-day physician charge for management of collection. For multiple day collections, these codes collection. For multiple day collections, these codes may be be billed on multiple days. may be be billed on multiple days.

Allogeneic Stem Cell Collection – 38205Allogeneic Stem Cell Collection – 38205 Physician Professional ComponentPhysician Professional Component

Allogeneic donor assessment for apheresis Allogeneic donor assessment for apheresis should be new patient – not consult H&P should be new patient – not consult H&P (there is not referring physician).(there is not referring physician).

Follow-up after care on a different day may Follow-up after care on a different day may use follow-up E&M codes. use follow-up E&M codes.

Autologous Stem Cell Collection – 38206Autologous Stem Cell Collection – 38206 Physician Professional ComponentPhysician Professional Component

Autologous pre-stem cell collection may be billed as Autologous pre-stem cell collection may be billed as a consult H&P if the physician doing apheresis is a consult H&P if the physician doing apheresis is different from the physician managing the cancer different from the physician managing the cancer care. This can be a “within specialty” consult; care. This can be a “within specialty” consult; however, this consult cannot be done on the day of however, this consult cannot be done on the day of collection. Wording of consult is important-or it collection. Wording of consult is important-or it will be a referral-transfer of care.will be a referral-transfer of care.

Autologous post-proceeding assessment is billable Autologous post-proceeding assessment is billable by E&M codes for follow-up as long as by different by E&M codes for follow-up as long as by different physicians doing routine cancer care. This cannot physicians doing routine cancer care. This cannot be billed on the day of collection. be billed on the day of collection.

Cell ProcessingCell Processing

Cell Processing Cell Processing RationaleRationale

Allow granularity for cell processing so Allow granularity for cell processing so that we do not utilize the old 86915 for that we do not utilize the old 86915 for red blood cell depletionred blood cell depletion

Codes moved to join other BMT related Codes moved to join other BMT related codes in CPT manualcodes in CPT manual

Removed reference to 88240 and 88241 Removed reference to 88240 and 88241 which were designed for laboratory which were designed for laboratory diagnostic procedures not therapeutic diagnostic procedures not therapeutic transplant servicestransplant services

Cell Processing Codes Cell Processing Codes RationaleRationale

CPT would only give codes to CPT would only give codes to procedural processes that are acceptedprocedural processes that are accepted

T-cell depletion and tumor purging have T-cell depletion and tumor purging have codes but not CD34 selectioncodes but not CD34 selection

Stem cell expansion still in research and Stem cell expansion still in research and we cannot set code for this servicewe cannot set code for this service

Cell ProcessingCell ProcessingGeneric Facility Pricing IssuesGeneric Facility Pricing Issues

These are per day codesThese are per day codes Markets sets prices, but in assessing cost to Markets sets prices, but in assessing cost to

determine institutional pricing consider including:determine institutional pricing consider including:– Technician time, supplies, machine use, machine Technician time, supplies, machine use, machine

depreciation, space costs, malpractice risk, quality depreciation, space costs, malpractice risk, quality assurance testing of an individual product, overhead assurance testing of an individual product, overhead

Pricing may include amortization of GMP Pricing may include amortization of GMP laboratory construction cost but must be laboratory construction cost but must be amortized over 10 yearsamortized over 10 years

RVU-RBRVS Committee established temporary RVU-RBRVS Committee established temporary RVU’s for all of these codes, but CMS chose not to RVU’s for all of these codes, but CMS chose not to recognize these rvu’srecognize these rvu’s

Cell ProcessingCell ProcessingPhysician Work EffortPhysician Work Effort

Includes:Includes:– Review of data important for cell processing Review of data important for cell processing

decisionsdecisions– Supervision of technicians performing an individual Supervision of technicians performing an individual

patient’s cell processingpatient’s cell processing– Review and interpretation of quality assurance Review and interpretation of quality assurance

procedures for an individual patient’s cells being procedures for an individual patient’s cells being processed, including flow cytometryprocessed, including flow cytometry

– Report on product adequacy and ability of cellular Report on product adequacy and ability of cellular product to meet expectationsproduct to meet expectations

– Time for report preparation and review of cell Time for report preparation and review of cell processingprocessing

– Malpractice riskMalpractice risk– Psychological stress Psychological stress


38207 Transplant preparation of hematopoietic 38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storageprogenitor cells; cryopreservation and storage

Cell Processing – 38207Cell Processing – 38207Suggested Suggested Facility Related ExpensesFacility Related Expenses• For cryopreservation and storage of bone marrow For cryopreservation and storage of bone marrow

or peripheral blood progenitor cells.or peripheral blood progenitor cells.

• Facility fees include tech time, laboratory supplies, Facility fees include tech time, laboratory supplies, machinery, machinery depreciation, and space machinery, machinery depreciation, and space costs. costs.

• If mononuclear cell processing was done prior to If mononuclear cell processing was done prior to

cryopreservation, it should be billed separately.cryopreservation, it should be billed separately.

• Cryopreservation charge should include all quality Cryopreservation charge should include all quality

assurance testing.assurance testing.

• After 2004, this code will include billing for all flowAfter 2004, this code will include billing for all flow

cytometry tests used for quality assurance testing. cytometry tests used for quality assurance testing.

Cell Processing – 38207Cell Processing – 38207Physician Professional ComponentPhysician Professional Component

Planning for cryopreservationPlanning for cryopreservation– How many stem cells or T-cells will be stored to meet How many stem cells or T-cells will be stored to meet

needs of transplant?needs of transplant?– What are anticipated issues?What are anticipated issues?

» Donor-recipient HLA/ABO/infectious disease serology, Donor-recipient HLA/ABO/infectious disease serology, recipient/donor size disparity recipient/donor size disparity

– What is RBC contamination of product?What is RBC contamination of product?– Which quality assurance procedures will be performed?Which quality assurance procedures will be performed?

» CD34, CD3 testsCD34, CD3 tests» Microbiology testing Microbiology testing

– Technician supervision Technician supervision – Review of freezer curvesReview of freezer curves– Report generation to review adequacy of cryopreserved Report generation to review adequacy of cryopreserved

product and the product’s ability to meet specificationsproduct and the product’s ability to meet specifications


38208 Transplant preparation of hematopoietic 38208 Transplant preparation of hematopoietic progenitor cells; thawing of a previously progenitor cells; thawing of a previously cryopreserved progenitor cell harvestcryopreserved progenitor cell harvest

Cell Processing – 38208Cell Processing – 38208SuggestedSuggested Facility Related Expenses Facility Related Expenses

• For thawing of harvest on the day of infusionFor thawing of harvest on the day of infusion• Includes all equipment, equipment Includes all equipment, equipment

depreciation, space costs, and technician time depreciation, space costs, and technician time used in thawing processused in thawing process

• Post thaw viability testingPost thaw viability testing


Includes:Includes:– Review of patient/donor data, freezer curves, Review of patient/donor data, freezer curves,

adequacy of cryopreserved productadequacy of cryopreserved product– Supervision of thawing, quality assurance testing of Supervision of thawing, quality assurance testing of

pre- and post-thaw product i.e. viability testing flow pre- and post-thaw product i.e. viability testing flow cytometry (obviously this does not hold up thaw)cytometry (obviously this does not hold up thaw)

– Need for special procedures for thawing processes Need for special procedures for thawing processes i.e. need for wash; concerns for incompatible RBC i.e. need for wash; concerns for incompatible RBC contaminationcontamination

– Report on product adequacy and ability to meet Report on product adequacy and ability to meet specificationsspecifications

– Preparation time for a thaw reportPreparation time for a thaw report– After 2004, flow cytometry will not be billed After 2004, flow cytometry will not be billed

separatelyseparately


38209 Transplant preparation of38209 Transplant preparation ofhematopoietic progenitor cells; washing of hematopoietic progenitor cells; washing of a previously cryopreserved progenitor cell a previously cryopreserved progenitor cell harvestharvest

Cell Processing – 38209Cell Processing – 38209Rationale and Suggested Facility Fee Rationale and Suggested Facility Fee

IssuesIssues For 2003, this is only for thawed cells For 2003, this is only for thawed cells

requiring a wash to remove DMSOrequiring a wash to remove DMSO Facility fee should include technician Facility fee should include technician

time, machinery, supplies and machinery time, machinery, supplies and machinery depreciationdepreciation

Post-wash viability testingPost-wash viability testing In 2004, this code will be redesigned for In 2004, this code will be redesigned for

thawing without wash and thawing with thawing without wash and thawing with washwash


Technician supervision of processTechnician supervision of process Quality assurance of product after washQuality assurance of product after wash Report generation to review adequacy of Report generation to review adequacy of

product and product’s ability to meet product and product’s ability to meet transplant specificationstransplant specifications


38210 T-Cell Depletion38210 T-Cell Depletion

Cell Processing – 38210Cell Processing – 38210SuggestedSuggested Facility Related Expenses Facility Related Expenses Facility fees may include machinery, machinery Facility fees may include machinery, machinery

depreciation, technician time, supplies, space depreciation, technician time, supplies, space costs, and quality assurance testingcosts, and quality assurance testing

If cryopreservation is needed, it may be billed If cryopreservation is needed, it may be billed separatelyseparately

If mononuclear cell separation not usually done If mononuclear cell separation not usually done prior, then may be billed separatelyprior, then may be billed separately

Tests to evaluate efficacy of T-cell depletionTests to evaluate efficacy of T-cell depletion Tests to evaluate viability after T-cell depletionTests to evaluate viability after T-cell depletion In 2004, will include flow cytometry testing, pre In 2004, will include flow cytometry testing, pre

and postand post


Assess donor/recipient suitability for T-cell Assess donor/recipient suitability for T-cell depletiondepletion

Assess HLA typing, donor/recipient size Assess HLA typing, donor/recipient size disparitydisparity

Assess quality of product coming to lab for T-cell Assess quality of product coming to lab for T-cell depletion, cell number, CD34 count, CD3 countsdepletion, cell number, CD34 count, CD3 counts

Supervision of technician performing processingSupervision of technician performing processing Assessment of efficacy of T-cell depletionAssessment of efficacy of T-cell depletion Review and interpretation of quality assurance Review and interpretation of quality assurance

testing testing Report preparation on quality of product to meet Report preparation on quality of product to meet

specifications specifications


38211 Tumor cell depletion38211 Tumor cell depletion


For autologous transplantationFor autologous transplantation Facility fees may include machinery, machinery depreciation, Facility fees may include machinery, machinery depreciation,

technician time, supplies, space costs and quality assurance technician time, supplies, space costs and quality assurance testingtesting

Testing to document efficacy of tumor purgingTesting to document efficacy of tumor purging Testing to document post-tumor purging cell viabilityTesting to document post-tumor purging cell viability Cryopreservation is always done and therefore should not be Cryopreservation is always done and therefore should not be

billed separatelybilled separately If mononuclear cell separation is always done, it should be If mononuclear cell separation is always done, it should be

included in pricing; if not, do not include in pricingincluded in pricing; if not, do not include in pricing After 2004, flow cytometry assessment must be included in After 2004, flow cytometry assessment must be included in

pricing and cannot be billed separatelypricing and cannot be billed separately


Assessment of need for tumor purgingAssessment of need for tumor purging Assessment of quality of product for tumor Assessment of quality of product for tumor

purgingpurging Supervision of technician performing tumor Supervision of technician performing tumor

purgingpurging Assessment of efficacy of tumor purgingAssessment of efficacy of tumor purging QA testing and reviewQA testing and review Report preparation on quality of product and Report preparation on quality of product and

that product meets specifications requestedthat product meets specifications requested


38212 Red blood cell removal38212 Red blood cell removal

Cell Processing – 38212Cell Processing – 38212SuggestedSuggested Facility Related Expenses Facility Related Expenses For a fresh allogeneic harvest; removal of For a fresh allogeneic harvest; removal of

RBC’s in preparation for transplantRBC’s in preparation for transplant Facility fees may include tech time, supplies, Facility fees may include tech time, supplies,

machinery and red cell depletion for a major machinery and red cell depletion for a major ABO incompatible bone marrow harvestABO incompatible bone marrow harvest

Testing of efficacy of RBC removalTesting of efficacy of RBC removal Testing of viability of progenitor cells after Testing of viability of progenitor cells after

RBC removalRBC removal In 2004, will include price for flow cytometry In 2004, will include price for flow cytometry

testing for quality assurance testing for quality assurance


Review of ABO typing prior to harvestReview of ABO typing prior to harvest Supervision of the processSupervision of the process Review of quality assurance testing Review of quality assurance testing Report preparation that product meets Report preparation that product meets

or does not meet specificationsor does not meet specifications


38213 Platelet depletion38213 Platelet depletion

Cell Processing – 38213Cell Processing – 38213RationaleRationale

For peripheral blood progenitor cell For peripheral blood progenitor cell harvest with a platelet soft spinharvest with a platelet soft spin

No RVU’s are assigned to this code No RVU’s are assigned to this code because no physician assessment is done because no physician assessment is done for quality of platelet addback given to for quality of platelet addback given to any donor with low platelet countsany donor with low platelet counts


38214 Plasma/volume depletion38214 Plasma/volume depletion


For a fresh bone marrow harvest and for For a fresh bone marrow harvest and for plasma removalplasma removal

Facility fees may include technician time, Facility fees may include technician time, supplies, and machinerysupplies, and machinery

For viability testing after plasma removalFor viability testing after plasma removal For 2004, will include flow cytometry For 2004, will include flow cytometry

testing for quality assurance of producttesting for quality assurance of product


Review of donor/recipient size and ABO Review of donor/recipient size and ABO blood typesblood types

Quality assurance of productQuality assurance of product Supervision of cell processingSupervision of cell processing Report generation of product meets or Report generation of product meets or

does not meet specificationsdoes not meet specifications


38215 38215 Cell concentration of Cell concentration of plasma, mononuclear, or buffy plasma, mononuclear, or buffy coat layercoat layer

Cell Processing – 38215Cell Processing – 38215RationaleRationale

For mononuclear cell preparation for For mononuclear cell preparation for major/minor ABO incompatibility on a major/minor ABO incompatibility on a fresh bone marrow harvest or for further fresh bone marrow harvest or for further cell processing procedurescell processing procedures

For occasional mononuclear cell For occasional mononuclear cell separation for further manipulation, if separation for further manipulation, if this is not routinely done for additional this is not routinely done for additional procedures then mononuclear cell procedures then mononuclear cell preparation may be billed separatelypreparation may be billed separately


Review of donor/recipient ABO Review of donor/recipient ABO incompatibility incompatibility

Supervision of cell processingSupervision of cell processing Quality assurance testing Quality assurance testing Report preparationReport preparation

38242 Donor Lymphocyte 38242 Donor Lymphocyte InfusionInfusion

This code is to administer a post allogeneic This code is to administer a post allogeneic donor lymphocyte infusion to treat relapse donor lymphocyte infusion to treat relapse of malignancy or infection after allogeneic of malignancy or infection after allogeneic bmt.bmt.

For boost of progenitor cells to treat For boost of progenitor cells to treat pancytopenia still use 38240, the allogeneic pancytopenia still use 38240, the allogeneic transplant infusion code.transplant infusion code.

CMS Issues CMS Issues

The Unprocessed Stem CellsThe Unprocessed Stem Cells

CPT editorial board refused our request for CPT editorial board refused our request for a code for generic quality assurance testinga code for generic quality assurance testing

Only option is for those patients to continue Only option is for those patients to continue to bill those services under 38240, 38241, to bill those services under 38240, 38241, and 38242and 38242

CMS IssuesCMS Issues CMS did not approve these cell processing CMS did not approve these cell processing

codes-38207-38215 and the code for unrelated codes-38207-38215 and the code for unrelated donor search and organ acquisition and 38204sdonor search and organ acquisition and 38204s

These codes can be used to bill these services to These codes can be used to bill these services to non-governmental payersnon-governmental payers

CMS has always had difficulty paying for CMS has always had difficulty paying for organ acquisition costsorgan acquisition costs

CMS moved these codes 38207 to 38215 to G-CMS moved these codes 38207 to 38215 to G-code section of HCPCS Level II and will pay code section of HCPCS Level II and will pay for cryopreservation and storage at rate for for cryopreservation and storage at rate for 88240 and 8824188240 and 88241

CMS IssuesCMS Issues With the new codes we probably are With the new codes we probably are

better off with the non-governmental better off with the non-governmental payerspayers

With CMS, we are no worse offWith CMS, we are no worse off Work on these codes brought increased Work on these codes brought increased

scrutiny to all apheresis and BMT related scrutiny to all apheresis and BMT related costcost

These codes were presented as facility These codes were presented as facility based. To do practice expensing would based. To do practice expensing would require a survey of how may pipettes, require a survey of how may pipettes, 4x4’s, we all use for every procedure4x4’s, we all use for every procedure

Critical Care E&M IssuesCritical Care E&M Issues

Critical CareCritical Care

Critical care can billed for service Critical care can billed for service rendered for patient not in MICUrendered for patient not in MICU

Advantage of critical care for E&M is Advantage of critical care for E&M is that it is a time based code. that it is a time based code.

Critical care pays more RVU’s than most Critical care pays more RVU’s than most complex inpatient E&M code (4 vs. 1.51, complex inpatient E&M code (4 vs. 1.51, respectively)respectively)


Critical care is direct delivery by a Critical care is direct delivery by a physician of medical care for a critically physician of medical care for a critically ill or critically injured patient. ill or critically injured patient.

A critical illness or injury acutely impairs A critical illness or injury acutely impairs one or more vital organ systems such that one or more vital organ systems such that there is a high probability of imminent or there is a high probability of imminent or life threatening deterioration in the life threatening deterioration in the patient’s condition. patient’s condition.

CPT 2003, Professional EditionCPT 2003, Professional Edition


Critical care involves high complexity Critical care involves high complexity decision making to assess, manipulate, decision making to assess, manipulate, and support vital system function(s) to and support vital system function(s) to treat single or multiple vital organ system treat single or multiple vital organ system failure and/or prevent further life failure and/or prevent further life threatening, deterioration of the patient’s threatening, deterioration of the patient’s condition.condition.

CPT 2003, Professional EditionCPT 2003, Professional Edition

Future ConcernsFuture Concerns


No one is totally satisfied with the resultsNo one is totally satisfied with the results

Billing these new codes will require more time and effortBilling these new codes will require more time and effort

Billing is moving to electronic transmittal of data. Each Billing is moving to electronic transmittal of data. Each item in bill needs either a CPT code or HSPCS level II item in bill needs either a CPT code or HSPCS level II codecode

Billing these codes is important in case rate payments Billing these codes is important in case rate payments because underlying charges determine how case rate because underlying charges determine how case rate payment is allocated within institutions. Even if bill is payment is allocated within institutions. Even if bill is paid as case rate, third party payers are to receive paid as case rate, third party payers are to receive itemized bill.itemized bill.


The January 26, 2003, edition of the New The January 26, 2003, edition of the New York Time’s indicated we and our York Time’s indicated we and our hospitals cannot expect to charge as hospitals cannot expect to charge as much as we are to pharmaceuticals. We much as we are to pharmaceuticals. We will need these services with legitimate will need these services with legitimate costs adequately to justify current case costs adequately to justify current case rates. rates.

ASBMT and the bmt community ASBMT and the bmt community owes a great debtowes a great debt

for the service of for the service of Samuel Silver, M.D., Ph.D. Samuel Silver, M.D., Ph.D.

and ASH staff and ASH staff

Their ongoing labors for financial Their ongoing labors for financial issues have not received the national issues have not received the national

accolades they deserveaccolades they deserve

review of new cpt codes affecting bmt services

Documents