January 2015 Update. Coding Sheet. Pre-Treatment Mapping and Microspheres Administration. Hospital Outpatient and Physician Services

Transcription

1 January 2015 Update Coding Sheet Pre-Treatment Mapping and Microspheres Administration Hospital Outpatient and Physician Services 1

2 SIR-Spheres microspheres Treatment Flow Chart (Performed in Outpatient Department) Phase 1: Pre-Treatment Evaluation Phase 2: SIR-Spheres microspheres Administration Patient Referral to Interventional Radiology SIR-Spheres microspheres (Ordered one week prior to treatment) Screening Lab Tests (Hepatic Panel - required for treatment) TREATMENT PLAN DOSE CALCULATION Pre-Treatment Mapping (Angiography and Embolization) Nuclear Medicine (Tc 99 MAA Scan for Shunting Lung) Radiation Oncology/Nuclear Medicine/or IR/AU Treatment Planning & Radiation Dosimetry DAY OF TREATMENT 20% or Greater Shunting? Patient may not be Eligible Less than 20% Shunting? Diagnostic Radiology CT Abdomen; MRA Abdomen (if applicable); 3D Post Processing; Baseline PET (if applicable) SIR-Spheres microspheres Administration Place arterial catheter; tumor embolization; Intra-arterial yttrium-90 administration Post-Procedure Observation (Liver imaging, SPECT or Planar) Post-Treatment Follow Up 6 weeks, 3 and 6 months Patient Eligible Schedule Treatment 2

3 SIR-Spheres Microspheres Therapy Coding and Medicare National Average Reimbursement 2015 Hospital Outpatient (OPPS) and 2015 Physician Services (MPFS) Medicare 2015 OPPS payment rates are reflective of Medicare 2015 OPPS Final Rule, Addendum B (January 2015 Update). Medicare physician payment rates included in this coding guide are based on current law, including the Pathway for SGR Reform Act of 2013 and the MPFS payment rates reflecting policies adopted in the CY 2015 Medicare Physician Fee Schedule Final Rule that appeared in the Federal Register on October 31, Physician payment rates are based on conversion factor $ , through March 31, The coding options listed in this guide are not intended as recommendations for coding, but only a suggested pathway to allow institutions and physicians to evaluate their own coding decisions. Not all institutions or physicians will use the codes indicated because of different clinical specialties involved or institutions specific coding practices or insurance payer requirements. All providers should be in agreement regarding the coding of the microspheres administration and concomitant procedures. Do not use different codes to describe the same service. Correct coding is based on documentation contained in the patient s medical records; therefore the provider should perform the procedure, document the procedure, code the procedure from the documentation, and finally bill the procedure. For purposes of space, this condensed coding sheet contains CPT codes that have been shortened or abbreviated from their original wording. Refer to your 2015 CPT book for full CPT code descriptors and explanations. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. FDA LABELED INDICATIONS FOR USE SIR-Spheres microspheres: Colorectal cancer metastasized to the liver in combination with hepatic arterial chemotherapy (FUDR) Full PMA approval Coding for administration of SIR-Spheres microspheres can be complex. There is no consensus or consistency in the coding/billing for the administration of SIR-Sphere microspheres. This coding guide provides SIR- Spheres Microspheres Pre-Treatment and Day of Treatment coding options. Payer policies should be reviewed for coverage & coding guidelines. IMPORTANT PROVIDER NOTICE! National Correct Coding Initiative (CCI) Edits may result in coding conflicts for various treatments and procedures. Providers should carefully review each quarter s CCI edit updates. CCI Edits may be downloaded from the CMS website at: Questions, concerns or comments regarding specific NCCI edits, may be submitted in writing to: National Correct Coding Initiative Correct Coding Solutions LLC P.O. Box 907 Carmel, IN Attention: Niles R. Rosen, MD, Medical Director & Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist Fax #:

4 Medicare National Payment Rates Code Code Description 2015 Hosp Outpatient 2015 Physician APC Payment* APC / Status Facility 1 (Hosp or ASC) Non-Fac 2 (Freestanding) SIR-SPHERES MICROSPHERES PRE-TREATMENT EVALUATION / MAPPING *Status Code J1: Comprehensive APC (C-APC). Effective 1/1/15, CMS created C-APCs using Status Indicator J1. All associated services will be packaged within the primary code (assigned as J1 status indicator). All pretreatment and mapping services will be packaged when billed on the same day as CPT code (J1). E&M Codes (consult your most recent CPT guide for full description of E&M coding options) Office/Clinic Visit - New Patient A minutes face-to-face with the patient and/or family $96.25* G0463 A $50.51 $ minutes face-to-face with the patient and/or family 0634 / Q3 $77.02 $ minutes face-to-face with the patient and/or family $ $ Office/Clinic Visit - Established Patient A minutes face-to-face with the patient and/or family $96.25* G0463 A $51.58 $ minutes face-to-face with the patient and/or family 0634 / Q3 $78.81 $ minutes face-to-face with the patient and/or family $ $ Selective Catheterizations for Diagnostic Procedure Selective catheter placement, arterial system; each first order $ $1, Selective catheter placement; initial second order abdominal $ $ $0.00 N Selective catheter placement; initial third order or more $ $1, Selective catheter placement; addl second order, third order $51.58 $ Hepatic Angiogram CTA, abdomen w contrast material(s), non-contrast images $281.94* 0662/Q3 $92.06 $ Angiography, visceral, radiological S&I $5,324.61* 0280/Q2 $57.32 $ Angiography, selective, radiological S&I Pkgd N $18.27 $ D Post-Processing (for liver volume) D Post Scan, not requiring image post-processing $10.03 $ D Post Scan; requiring image post processing (Cone Beam CT) (Do not bill in conjunction with CPT code 78580) $0.00 N $40.12 $64.48 CT Acquisition (may be billed in conjunction with CPT code 76377) or Computed tomography, abdomen; without contrast material $120.02* 0332/Q3 $60.54 $ or Computed tomography, abdomen; with contrast material(s) $240.92* 0283/Q3 $65.20 $ Computed tomography, abd; w & wo contrast (Triple-phase CT) $269.71* 0333/Q3 $71.29 $ Pre-Treatment Arterial Embolization Vascular embolization or occlusion, inclusive of all radiological S&I, intra-procedural road mapping and imaging guidance necessary to complete the intervention; other than hemorrhage or tumor Nuclear Medicine Imaging (coding options will vary based on provider preference) $ 9, / J1* $ $7, Liver imaging, static $373.05* 0394/S $21.85 $ Liver imaging (SPECT) $ /S $34.39 $ Liver Spleen Imaging $ /S $24.36 $ C Optional Procedure (hospital) MRA Abdomen, with contrast material $427.04* 0284/Q3 NA NA Optional Procedure (physician) MRA Abdomen, wo & with contrast NA NA $90.99 $ Pulmonary perfusion imaging, particulate (Do not bill in conjunction with CPT code 76377) $315.89* 0401/S $36.90 $ A Medicare requires use of HCPCS code, G0463 for hospital use only, representing any outpatient clinic visit. 4 *Status Code J1: Comprehensive APC (C-APC). All associated services will be packaged within the primary code.

5 Medicare National Payment Rates Code Code Description 2015 Hosp Outpatient 2015 Physician Nuclear Medicine Imaging (continued) APC Payment* APC / Status Facility 1 (Hosp or ASC) Non-Fac 2 (Freestanding) Radiopharmaceutical localization of tumor; limited area $377.33* 0406/S $33.67 $ Radiopharmaceutical localization of tumor; whole body, single day $706.73* 0414/S $42.99 $ Radiopharmaceutical localization of tumor; tomographic (SPECT) $706.73* 0414/S $53.02 $ Optional Procedure - PET; limited area $1,286.23* 0308/S $79.88 $00/Carrier Optional Procedure - PET; skull base to mid-thigh $1,286.23* 0308/S $97.80 $00/Carrier Optional Procedure - PET, whole body $1,286.23* 0308/S $ $00/Carrier A Technetium TC-99m macro-aggregated albumin Note: Do NOT code CPT for the injection of TC99 MAA on the mapping day as this is considered part of the nuclear medicine exam. Pkgd N NA NA SIR-SPHERES MICROSPHERES ADMINISTRATION / IMPLANT *Status Code J1: Comprehensive APC (C-APC). Effective 1/1/15, CMS created C-APCs using Status Indicator J1. All associated services will be packaged within the primary code (J1 status indicator). All services rendered on day of implant (except y-90 brachytherapy sources), will be packaged when billed on the same day as CPT code (J1). Selective Catheterization Selective catheter placement, arterial system; each first order $ $1, Selective catheter placement; initial second order abdominal $ $ $0.00 N Selective catheter placement; initial third order or more $ $1, Selective catheter placement; addl second order, third order $51.58 $ Hepatic Angiogram Angiography, visceral, radiological S&I $5,324.61* 0280/Q2 $57.32 $ Angiography, selective, radiological S&I Pkgd N $18.27 $88.12 SIR-Spheres Microspheres Administration / Implant Coding Options for Billing of Sources (Yttrium-90 Microspheres) C2616 Brachytherapy source, yttrium-90 (non-stranded) (required by Medicare and some private payers) S2095 Q3001 Trans-catheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres (not used by Medicare; required by BC/BS) Radioelements for brachytherapy, any type, each (Medicare freestanding physician office only; private payer guidelines vary) CODING OPTION 1: Two Doctor Model (IR with separate AU) IR Codes Vascular embolization or occlusion, inclusive of all radiological S&I, intra-procedural road mapping/imaging guidance necessary to complete the intervention; venous, for tumors, organ ischemia, or infarction $15, /U NA NA Contact private payer for coding and payment guidelines NA NA NA Invoice Payment $9, / J1* $ $9, AU Codes - Treatment planning should be billed and dictated separately prior to microsphere admin Radiopharmaceutical therapy, by intra-arterial particulate admin $276.93* 0407/S $ $00/Carrier Basic Dosimetry Calculation $113.17* 0304/S $32.24 $ Supervision, handling, loading of radiation source (Medicare packages this service with CPT 79445). Pkgd N $54.09 $ or Treatment Planning; complex Treatment planning should be $0.00 B $ $ Treatment Planning; intermediate billed & dictated separately prior to microsphere admin $0.00 B $ $ *Status Code J1: Comprehensive APC (C-APC). All associated services will be packaged within the primary code.

6 Medicare National Payment Rates Code Code Description 2015 Hosp Outpatient 2015 Physician Coding Option 1: AU Codes (continued) (Optional) Special Medical Radiation Physics Consultation Note: Requires a written order by the physician APC Payment* APC / Status Facility 1 (Hosp or ASC) Non-Fac 2 (Freestanding) $113.17* 0304/S NA $ Special Treatment Procedure (must meet specific criteria 5 ) $507.75* 0412/S $ $ CODING OPTION 2: One Doctor Model (IR/AU) (one doctor performs both roles) Vascular embolization or occlusion, inclusive of all radiological S&I, intra-procedural road mapping and imaging guidance necessary to complete the intervention; venous, for tumors, organ ischemia, or infarction $9, / J1* $ $9, Radiopharmaceutical therapy, by intra-arterial particulate admin $276.93* 0407/S $ $00/Carrier Basic Dosimetry Calculation $113.17* 0304/S $32.24 $ Supervision, handling, loading of radiation source (Medicare packages this service with CPT 79445). Pkgd N $54.09 $ or Treatment Planning; complex Treatment planning should be $0.00 B $ $ Treatment Planning; intermediate billed & dictated separately prior to microsphere admin $0.00 B $ $ Special Treatment Procedure (patient must meet specific criteria) 5 $507.75* 0412/S $ $ CODING OPTION 3: One Doctor Model (IR/AU) (one doctor performs both roles) Society of Interventional Radiology (SIR) Recommended One-Doctor Model Coding Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping and imaging guidance; venous, for tumors, organ ischemia, or infarction $9, / J1* $ $9, Radiopharmaceutical therapy, by intra-arterial particulate admin $276.93* 0407/S $ $00/Carrier Treatment Planning; complex $0.00 B $ $ Therapeutic radiology simulation-aided field setting; complex $ /S $80.96 $ Supervision, handling, loading of radiation source (Medicare Pkgd N $54.09 $97.05 packages this service with CPT 79445). Note: SIR does not indicate basic dosimetry (CPT 77300) in their coding recommendations. CODING OPTION 4: Two Doctor Model (IR with separate AU) Society of Interventional Radiology (SIR) Recommended Two-Doctor Model Coding 1 IR Codes Vascular embolization or occlusion, inclusive of all radiological S&I, intraprocedural road mapping and imaging guidance ; venous, for tumors, organ ischemia, or infarction AU Codes Interstitial radiation source application; complex (Medicare NCCI edit with 37243) $9, / J1* $ $9, $ /Q3 $ $ Treatment Planning; complex $0.00 B $ $ Therapeutic radiology simulation-aided field setting; complex $ /S $80.96 $ Supervision, handling, loading of radiation source Pkgd N $54.09 $97.05 Note: SIR does not indicate basic dosimetry (CPT 77300) in their coding recommendations 1 CODING OPTIONS 3 and 4 are based on recommendations as cited in the Society of Interventional Radiology and American College of Radiology, 2015 Interventional Radiology Coding Update: Coding for Endovascular and Interventional Procedures and Services. Edition 15. NOTE: Current and previous CCI edits prohibit the billing of CPT and the tumor embolization code (CPT 37243) and the deleted embolization code CPT on the same day. CMS states CPT is a misuse of the code for SIRT. The alternative administration code CPT should be used. All coding options should be reviewed for compliance prior to implementation. 6 *Status Code J1: Comprehensive APC (C-APC). All associated services will be packaged within the primary code.

7 Medicare National Payment Rates Code Code Description 2015 Hosp Outpatient 2015 Physician APC Payment* APC / Status Facility 1 (Hosp or ASC) Non-Fac 2 (Freestanding) Day of Implant (continued) Fluoroscopy Fluoroscopy (separate procedure), up to 1 hour physician time $ /S $8.96 $47.29 Post SIRT Liver Imaging Liver imaging, static $373.05* 0394/S $21.85 $ Liver imaging (SPECT) $ /S $34.39 $ Liver Spleen Imaging $ /S $24.36 $ Radiopharmaceutical localization of tumor; limited area $377.33* 0406/S $33.67 $ CCI edit with modifier allowed Radiopharmaceutical localization of tumor; tomographic (SPECT) CCI edit Modifier allowed $706.73* 0414/S $53.02 $ Post-Treatment Imaging CT Abdomen $269.71* 0333/Q3 $71.29 $ Radiopharmaceutical localization of tumor; whole body, single day $706.73* 0414/S $42.99 $ Optional Procedure- Tumor Imaging, PET, whole body $1,286.23* 0308/S $ $00/Carrier Footnotes 1 Physician facility payment refers to physician s professional services provided in a facility such as a hospital or ASC; 2 Physician non-facility payment refers to physician s professional services provided in the physician freestanding facility; 3 HCPCS code C8900 is appropriate for Medicare billing of hospital outpatient and ASC services; CPT should be used for private payer coding and for physician service; 4 Some Medicare contractors may deny A9540 when used in conjunction with 78205/ Alternatively, some Medicare contractors may deny the post-procedure liver imaging codes in absence of a radiopharmaceutical HCPCS. Contact your Medicare contractor for specific requirements. A letter of medical necessity may be required for consideration of coverage; (Special Treatment Procedure): Code used in circumstances requiring extra work over and above basic dosimetry calculation: Patient has had previous chemo, or receiving concurrent chemo or external beam radiation to the body or liver. AU must review current CT scan, liver function studies and ECOG performance status to determinate the percentage the yttrium-90 dose needs to be adjusted to take into account the previous treatments. Most often used as a re-treatment code. Carrier indicates Medicare has not established values for this code and will require claim review OR a non-facility practice expense has not been established as the service is typically furnished in the facility setting. Claims will be reviewed for payment consideration. If contractor determines the service can be furnished in the non-facility setting, payment will be made at the facility rate. APC Status Key: B = Not paid under OPPS; J1 = Comprehensive APC, all services provided on the same day as a J1 code(s) will be pkgd; N = Incidental services, packaged; Q1 = Not eligible for separate payment when performed in conjunction with the embolization procedure; Q3 = Codes that may be paid through a composite APC based on composite-specific criteria or separately through single code APCs when the criteria are not met; S = Significant procedure, not discounted when multiple. 7 *Status Code J1: Comprehensive APC (C-APC). All associated services will be packaged within the primary code.

8 ICD-9-CM CODES ICD-9 Diagnosis Code Code primary cancer. The following diagnosis code range is specific to colorectal cancer (SIR-Spheres microspheres is approved for colorectal cancer that has metastasized to the liver). If the cancer is other than colorectal metastases, consult your ICD-9-CM code book for appropriated coding Malignant neoplasm of colon Malignant neoplasm of rectum Secondary malignant neoplasm of liver ICD-10 CODES ICD 10 Diagnosis Code Code primary cancer. The following diagnosis code range is specific to colorectal cancer (SIR-Spheres microspheres is approved for colorectal cancer that has metastasized to the liver). If the cancer is other than colorectal metastases, consult your ICD-9-CM code book for appropriated coding. C18.0 C18.9 Malignant neoplasm of colon C19.0 C21.1 Malignant neoplasm of rectum C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct MICROSPHERES REVENUE CODES Revenue Code Descriptor 0278 Medical / Surgical Supplies Other Implants Hospital Charge Master Reminder The hospital s charge master should reflect the following codes for the microspheres o C2616 (Brachytherapy source, yttrium-90) and/or o S2095 (Trans-catheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres: BC/BS) Coding of SIR-Spheres Microspheres is dependent upon the patient s health insurance coverage. Private payer guidelines should be consulted for appropriate coding and payment. NOTE: It is important to consult with the hospital finance department to determine the appropriate charges for the microspheres. 8

9 FREQUENTLY ASKED QUESTIONS GENERAL QUESTIONS APPLICABLE TO ALL SITES OF SERVICE Q1. Is SIR-Spheres microspheres considered a brachytherapy or radiopharmaceutical device? A. A brachytherapy device is defined by CMS as a seed or seeds (or radioactive source) that are themselves radioactive, meaning that the sources contain a radioactive isotope 3. Brachytherapy devices require penetration of the skin or surgery to insert the device directly into the interstitial tumor bed. Unlike Radiopharmaceuticals, SIR-Spheres microspheres have no therapeutic chemical or metabolic effect. They represent a permanent form of brachytherapy that continues to deposit radiation until the radionuclide is completely decayed, leaving the biocompatible resin microsphere implanted in the liver. The term Radiopharmaceutical means a radioactive isotope that contains by-product material combined with chemical or biological material. Its therapeutic purpose is designed for enabling the production of a useful image for use in a diagnosis of a medical condition. [1] Source: CRF TITLE 42 CHAPTER 7 SUBCHAPTER XVIII Part B 1395l Section H [2] Society of Interventional Radiology, 2007 March-April Newsletter, Volume 20 number 2 pages [3] Source: CFR TITLE 42.CHAPTER 23,Division A.SUBCHAPTER X Q2. How are the 2014 embolization codes used for the Mapping and Day of Treatment procedures? A. CPT Code was eliminated December 31, The 2014 embolization codes that should be used for the work required for the mapping or planning angiogram are CPT (Arterial embolization or occlusion) and for the microsphere treatment use CPT code (Vascular embolization or occlusion for tumor destruction). Both codes include radiological S&I, intra-procedural guidance, road mapping and the imaging necessary to document completion of the procedure. Codes(s) for catheter placement (s) and diagnostic studies are reported separately. In addition to following CPT guidelines for coding, Medicare s correct coding initiative as well as payer medical policies should be reviewed for coding guidelines. Q3. What is a Comprehensive APC (C-APC)? A. A comprehensive APC (C-APC) is designed to include the provision of a primary service and all adjunctive services and supplies provided to support the delivery of the primary service. Under the comprehensive APC, the entire claim, including the primary service (identified by status code J1), is associated with a single comprehensive service and all costs reported on the claim would be assigned to that service. The SIR- Spheres microspheres procedure is driven by J1 codes for both the pretreatment/mapping phase (CPT 37242) as well as the day of implant (CPT 37243). All codes on both days of service will be bundled and paid under C- APC Brachytherapy sources (yttrium-90 SIR-Spheres microspheres) will continue to be paid separately and in addition to the C-APC payment for the day of implant. Q4. Do certain payers have specific coding requirements for the procedure? A. Many national and regional payers have coverage policies in place recommending specific procedure code(s). We recommend checking with the payer to determine if a coverage policy is in effect. Note: Many payers have not established specific coding guidelines and assess the claims at the time of the procedure. 9

10 Q5. Do Medicare and Medicaid provide coverage for yttrium-90 treatments? A. Medicare reimburses providers for yttrium-90 under HCPCS code C2616 in the hospital outpatient setting. Per the FDA approved package insert, SIR-Spheres microspheres are indicated for the treatment of unresectable metastatic liver tumors from primary colorectal cancer with adjuvant intra-hepatic artery (HAC) FUDR (Floxuridine) chemotherapy. We recommend checking your local Medicare contractor s website to determine if there is a local coverage determination (LCD) policy for yttrium-90 or Radioembolization therapy. The local Medicare contractor will determine the appropriate codes to use when reporting the service. Wisconsin Physician Services (WPS) MAC Jurisdiction 5 (IA, KS, NE, and MO) and Jurisdiction 8 (IN, MI) do have a written local coverage determination (LCDL30197) policy for SIR-Spheres, which may be found at Noridian Services has a written policy under (A52208) for jurisdiction J-F (AK,AZ,ID,MT,ND,OR,SD,UT,WA,WY) and Jurisdiction J-E (CA,HI,NV) can be found at In regards to Medicaid payment for the SIR-Spheres microspheres, the hospital should review their Medicaid fee schedule to determine the level of reimbursement, if any, for C2616. We recommend checking with your state Medicaid agent for more information. Q6. Which private payers have positive medical directives for SIR-Spheres microspheres? A. Many private payers have realized the efficacy of the SIR-Spheres microspheres procedure and as a result have issued positive coverage policies for treatment. These payers include Aetna, Anthem, Cigna, United Healthcare, Health Net, Humana, Oxford and most Blue Cross/Blue Shield plans. Many other plans cover the treatment on a case by case basis. Contact your Sirtex Reimbursement Advocate at , Ext 717 for information specific to your payer health plans. Q7. How do I indicate that I am using the SIR-Spheres microspheres for off-label use? A. In general, Medicare contractors require procedures involving off-label use of medical technologies be coded according to the usual coding rules. If there are appropriate listed codes, they should be used to describe the procedure. If not, the appropriate not otherwise classified (NOC) or unlisted procedure codes should be used. In addition, it is recommended that supporting clinical documentation for medical necessity be submitted with the professional and facility claim. Providers concerned about clearly indicating off-label usage may note off label use in the remarks/comments section on the hospital claim form. NOTE: SIR-Spheres microspheres are indicated for the treatment of nonresectable metastatic colorectal cancer in combination with intra-arterial FUDR chemotherapy. Information regarding other disease states or agents in combination with this device is different from the approved USA labeling for SIR-Spheres microspheres. It is recommended that all off-label claims be submitted with adequate medical necessity documentation. Providers may consider issuing an Advanced Beneficiary Notification of Noncoverage (ABN) for original Medicare Beneficiaries before providing the service. Refer to Medicare Learning Network for instructions on the use of an ABN. Q8. What diagnosis codes are considered off-label for SIR-Spheres microspheres? A. All diagnosis codes are considered off-label for SIR-Spheres microspheres except for colorectal cancer metastasized to the liver (ICD-9 diagnosis code 197.7, billed in conjunction with ). 10

11 Q9. The 2015 SIR coding guidance states that CPT can be billed by the TWO Doctor model AU (Authorized User). Are there any NCCI edits that preclude the use of CPT when the AU is a Radiation Oncologist or Nuclear Medicine physician? A. There is controversy surrounding this coding. The 2015 SIR guidance recommends the use of CPT if the program uses a TWO doctor model. The IR (Interventional Radiologist) and a separate AU (Authorized User), either a Radiation Oncologist or Nuclear Medicine, work together to perform the procedure. In this scenario the AU delivers or supervises the administration of the SIR-Spheres microsphere therapy. The Society of Interventional Radiology recommends use of CPT code to describe the work of application of an interstitial radiation source, (complex). If the second physician- the AU- has material involvement in the planning, dosimetry and administration of the microspheres, CPT may be used. These codes should not be reported by an AU for intraoperative work with another physician who surgically places catheters interstitially unless the authorized user also applies the radiation source at the same patient encounter. Additionally, if the AU is billing CPT 77778, CPT code should not be billed in that same encounter. Note: In 2014 a CCI edit was implemented by CMS which prohibited billing CPT with the treatment day embolization code CPT under APC CMS stated that CPT should not be billed for SIRT therapy because it is a misuse of the code. CPT describes interstitial placement of the particles into the tissue. SIR-Spheres microspheres are administered into the artery where they will lodge in the end arterioles in the hepatic tumor bed. Coding for the two doctor model should be reviewed by coding compliance to assure that the coding supports the services performed and meets local coverage polices. Source: 2015 Interventional Radiology Coding Update: Coding for Endovascular and Interventional Procedures and Services. Edition 15, Society of Interventional Radiology and American College of Radiology. HOSPITAL OUTPATIENT SPECIFIC QUESTIONS Q10. Does Medicare pay for SIR-Spheres microspheres separately from the procedure in the hospital outpatient setting? A. As mandated under the 2003 Medicare Prescription Drug and Improvement Act (MMA) and the 2009 Final Rule, SIR-Spheres microspheres are classified as a permanent brachytherapy device and as such are reimbursed (under C2616) separately from the implant procedure. Section 1833(t) (2) (H) of the (MMA) Act mandated the creation of additional groups of covered OPD services that classify devices of brachytherapy consisting of a seed or seeds (or radioactive source) ( brachytherapy sources ) separately from other services or groups of services. The additional groups must reflect the number, isotope, and radioactive intensity of the brachytherapy sources furnished and include separate groups for palladium-103 and iodine-125 sources. Q11. How much does Medicare allow for the yttrium-90 device in the hospital outpatient setting? A. Effective January 1, 2015, Medicare reimbursement for SIR-Spheres microspheres (HCPCS C2616, Brachytherapy source, (Yttrium-90 non-stranded) is paid separately under a prospective payment rate of $15, with an unadjusted patient co-pay of $3, Note: C2616 is not subject to the hospital wage index adjustment; therefore the dose amount should not be discounted. Q12. Does the Medicare outpatient deductible apply to the SIR-Spheres microspheres? A. Yes. Prior to January 1, 2010, SIR-Spheres microspheres were paid under the hospital s cost-to-charge ratio and not subject to the Medicare outpatient deductible. However, under the prospective payment methodology, SIR-Spheres microspheres is subject to the same Medicare deductible and co-pay policies applicable to other hospital outpatient procedures. 11

12 PHYSICIAN FREESTANDING CENTER SPECIFIC QUESTIONS Q13. Does Medicare pay for SIR-Spheres microspheres separately from the procedure in the physician freestanding center? A. It is unclear if Medicare will pay for the microspheres in the freestanding facility. If the SIR-Spheres microspheres are covered, HCPCS code Q3001 should be used to indicate yttrium-90 microspheres. A copy of the invoice should also be submitted to the payer. We recommend contacting your local Medicare Part B contractor to determine appropriate coding and payment guidelines. Q14. How much does Medicare allow for the yttrium-90 device in the Freestanding Center setting? A. It is unclear how Medicare will reimburse for the SIR-Spheres microspheres in the freestanding facility. We recommend contacting your local Medicare Part B Contractor to determine appropriate coding and payment guidelines for Q3001 in the freestanding center. 12

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