January Coding Sheet. Pre-Treatment Mapping and Microspheres Administration. Hospital Outpatient, ASC and Physician Services
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1 January 2016 Coding Sheet Pre-Treatment Mapping and Microspheres Administration Hospital Outpatient, ASC and Physician Services
2 SIR-Spheres microspheres Treatment Flow Chart (Performed in Outpatient Setting OPPS ) 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
3 SIR-Spheres microspheres Therapy Coding and Medicare National Average Reimbursement 2016 Hospital Outpatient (OPPS), Ambulatory Surgery Center (ASC) and 2016 Physician Services (MPFS) Medicare 2016 OPPS payment rates are reflective of Medicare 2016 OPPS Final Rule, Addendum B 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 CY 2016 Medicare Physician Fee Schedule Final Rule that appeared in the Federal Register on November 1, 2015, with updated conversion factor files published January 15, Physician payment rates are based on conversion factor $ through December 31, 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. FDA LABELED INDICATIONS FOR USE SIR-Spheres microspheres: Colorectal cancer metastasized to the liver in combination with hepatic arterial chemotherapy (FUDR) Full PMA approval Provider of Service Place of Service Code Hospital Outpatient 22 Ambulatory Surgery Center (ASC) Physician Freestanding Office Medicare Payment Methodology Hospital Outpatient Prospective Payment System (OPPS) payments made based on CPT codes under Ambulatory Payment Classifications (APC) 24 ASC Payment System is linked to the OPPS, paying ~65% of the APC payment 11 Medicare Physician Fee Schedule (MPFS) payments are made based on relative values assigned to CPT codes (work, practice and malpractice expense) 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 (Fax #: ) P.O. Box 907 Carmel, IN Attention: Niles R. Rosen, MD, Medical Director & Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist Page 3 Rights Reserved. 281-U-0416.
4 Coding Options for SIR-Spheres microspheres Therapy Pretreatment and Mapping Medicare January 2016 CPT APC CPT Description 1 See 2016 CPT Guide for full descriptions Hospital Outpatient Facility Payment Ambulatory Surgery Center Physician Payment Physician (Facility) 2 Physician (Non-Facility) 3 E&M CODES E&M codes will vary; consult your most recent CPT Coding Guide for E&M coding options and guidelines PRE-PLANNING MAPPING CODING 4 (See Coding Scenarios 1 and 2 following this section for Medicare base case coding examples for one and two doctor models) Selective Catheterizations for Diagnostic Procedure NA Selective catheter placement; initial second order and $00 $00 $282 $ NA ; initial third order or more $00 $00 $334 $1, NA ; additional second order, third order and beyond $00 $00 $52 $156 Hepatic Angiogram Angiography, visceral, radiological S&I $2,718 $00 $57 $ NA Angiography, selective, radiological S&I $0 $00 $18 $88 Embolization (if indicated) (J1 * ) Arterial embolization or occlusion, inclusive of all radiological S&I; arterial other than hemorrhage or tumor $9,542 $5,984 $517 $7,806 Treatment Planning NA Treatment Planning; intermediate OR $0 $0 $115 $ NA Treatment Planning; complex $0 $0 $168 $168 3-D Post-Processing (for liver volume) N 3D Post Scan, not requiring image post-processing $0 $0 $10 $ N Cone Beam CT (Medicare NCCI edit with 78580) $0 $0 $40 $65 CT Acquisition (may be billed in conjunction with CPT code 76377) CTA without contrast material $112 $62 $61 $ CTA; with contrast material(s) $236 $132 $65 $ CTA; with and without contrast $236 $132 $72 $ CTA; abdomen & pelvis, with & without contrast $236 $132 $92 $92 Imaging (coding options will vary based on provider preference) Liver imaging, static $332 $186 $21 $ Liver imaging (SPECT) $332 $186 $34 $ Liver Spleen Imaging $332 $186 $25 $ Pulmonary perfusion imaging (Medicare NCCI edit 76377) $332 $186 $37 $ Radiopharmaceutical localization of tumor; limited area $332 $186 $34 $ Radiopharmaceutical localization whole body, single day $441 $246 $43 $ Radiopharmaceutical localization of tumor (SPECT) $441 $246 $53 $ Optional Procedure - PET; limited area $1,285 $718 $78 $ Optional Procedure - PET; skull base to mid-thigh $1,285 $718 $96 $ Optional Procedure - PET, whole body $1,285 $718 $123 $123 A N Technetium TC-99m macro-aggregated albumin $0 $0 NA $0 1 Some CPT descriptors have been shortened for purposes of brevity. See your CPT Guide for full descriptors and coding guidelines. 2 Facility payment refers to professional services rendered in a facility setting such as hospital or ASC. 3 Non-Facility payment refers to professional services provided in the physician freestanding office, surgical or cancer center. 4 The possible coding options listed in this section are based on Medicare guidelines and society recommendations. Medicare base case coding scenarios typical for one mapping and one treatment in the hospital outpatient or ASC setting follow this section. 5 Treatment planning should be billed and dictated separately prior to microspheres administration, 6 Do NOT code CPT for the injection of TC99 MAA on the mapping day as this is considered part of the nuclear medicine exam. Page 4 Rights Reserved. 281-U-0416.
5 Coding Options for SIR-Spheres microspheres Therapy Day of Treatment (Administration / Implant) Medicare January 2016 CPT Shortened CPT Description 1 See 2016 CPT Guide for full descriptions Hospital Outpatient Facility Payment Ambulatory Surgery Center Physician Payment Physician (Facility) 2 APC DAY OF TREATMENT CODING 4 (See Coding Scenarios 1 and 2 following this section for Medicare base case coding examples for one and two doctor models) Selective Catheterizations Physician (Non-Facility) NA Selective catheter placement; initial second order and $00 $00 $282 $ NA ; initial third order or more $00 $00 $334 $1, NA ; additional second order, third order and beyond $00 $00 $52 $156 Hepatic Angiogram Angiography, visceral, radiological S&I $2,718 $00 $57 $ NA Angiography, selective, radiological S&I $0 $00 $18 $88 Coding Options for Billing of Sources (Yttrium-90 Microspheres non stranded) C Brachytherapy source (yttrium-90 non-stranded) $16,021 $16,021 NA Invoice S2095 NA Transcatheter embo for tumor destruction using yttrium- 90 microspheres Private Payer Contract price Private Payer Contract Price NA Private Payer Microspheres Administration (See Coding Scenarios 1 and 2 for coding examples of One doctor and Two doctor model) (J1*) Tumor embolization or occlusion, inc of all radiological S&I; venous, for tumors, organ ischemia, or infarction $9,542 $5,984 $609 $9, Simulation, Complex $291 $163 $82 $ Basic Dosimetry Calculation $107 $34 $33 $ Special Medical Radiation Physics Consultation $166 $93 $123 $ Special Treatment Procedure $505 $47 $109 $ Interstitial radiation source application; complex $696 $367 $417 $ N Supervision, handling, loading of radiation source $0 $0 $15 $ Radiopharmaceutical therapy, by intra-arterial particulate admin $250 $139 $117 $117 Post Treatment Imaging (coding options will vary based on provider preference) CTA; with and without contrast $236 $132 $72 $ CTA; abdomen & pelvis, with & without contrast $236 $132 $92 $ Liver imaging, static $332 $186 $21 $ Liver imaging (SPECT) $332 $186 $34 $ Liver Spleen Imaging $332 $186 $25 $ Pulmonary perfusion imaging (Medicare NCCI edit 76377) $332 $186 $37 $ Radiopharmaceutical localization of tumor; limited area $332 $186 $34 $ Radiopharmaceutical localization whole body, single day $441 $246 $43 $ Radiopharmaceutical localization of tumor (SPECT) $441 $246 $53 $ Optional Procedure - PET, whole body $1,285 $718 $123 $123 7 Use of this code requires a written order by the physician. 8 Used in circumstances requiring extra work over and above basic dosimetry calculation: Patient with previous chemo, is receiving concurrent chemo, or external beam radiation to the body/liver. AU must review current CT scan, liver function studies and ECOG performance status to determinate % yttrium-90 dose to be adjusted taking into account previous treatments. Often used as a re-treatment code. 9 Medicare NCCI edit with Medicare packages this service with CPT Page 5 Rights Reserved. 281-U-0416.
6 Coding Options for SIR-Spheres microspheres Therapy MEDICARE BASE CASE CODING SCENARIOS FACILITY January 2016 The following coding examples are specific to Medicare base-case coding scenarios typical for one mapping and one treatment in the hospital outpatient or ASC setting for both a one-doctor and a two-doctor model. Other procedures and imaging may be performed. Society coding recommendations (SIR and ASTRO) vary and are not included in the example scenarios. Contact Sirtex for additional information. FACILITY CODING: SCENARIOS 1 AND 2 CPT APC CPT Description PRE-PLANNING MAPPING CODING Hospital Outpatient (OPPS) Facility Payment Ambulatory Surgery Center (ASC) Selective Catheterizations for Diagnostic Procedure NA Selective catheter placement; initial second order abdomen $00 $ NA ; initial third order or more $00 $ NA ; additional second order, third order and beyond $00 $00 Hepatic Angiogram Angiography, visceral, radiological S&I $2,718 $00 Embolization (if indicated) (J1 * ) Arterial embolization or occlusion, inclusive of all radiological S&I; arterial other than hemorrhage or tumor $9,542 $5,984 Imaging (coding options will vary based on provider preference) Liver imaging, static OR $332 $ Liver imaging (SPECT) $332 $ Pulmonary perfusion imaging (Medicare NCCI edit 76377) $332 $186 A N Technetium TC-99m macro-aggregated albumin $0 $0 DAY OF TREATMENT CODING Selective Catheterizations NA Selective catheter placement; initial second order abdomen $00 $ NA ; initial third order or more $00 $ NA ; additional second order, third order and beyond $00 $00 Coding Options for Billing of Sources (Yttrium-90 Microspheres) C Brachytherapy source (yttrium-90 non-stranded) $16,021 $16,021 S2095 NA Transcatheter embo for tumor destruction using yttrium-90 microspheres Private Payer Contract Price Private Payer Contract Price Microspheres Administration (J1*) Tumor embolization or occlusion, inc of all radiological S&I; venous, for tumors, organ ischemia, or infarction $9,542 $5, Basic Dosimetry Calculation $107 $ Radiopharmaceutical therapy, by intra-arterial particulate admin $250 $139 Post Treatment Imaging (coding options will vary based on provider preference) Liver imaging, static $332 $ Liver imaging (SPECT) $332 $ Do NOT code CPT for the injection of TC99 MAA on the mapping day as this is considered part of the nuclear medicine exam. 12 CPT codes and will be packaged with payment for CPT CPT code is assigned to a Comprehensive APC (J1), which means all services performed on the day of treatment will be packaged (CPT is always performed/billed on day of treatment). Page 6 *Status Code J1: Comprehensive APC (C-APC). In 2015 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) or (J!) (with the exception of Yttrium-90 brachytherapy sources billed under C2616). Rights Reserved. 281-U
7 Facility Payment CPT APC CPT Description Hospital Outpatient (OPPS) Ambulatory Surgery Center (ASC) CTA; with and without contrast $236 $ CTA; abdomen & pelvis, with & without contrast $236 $132 Coding Options for SIR-Spheres microspheres Therapy MEDICARE BASE CASE CODING SCENARIOS PHYSICIAN January 2016 The following coding examples are specific to Medicare base-case coding scenarios typical for one mapping and one treatment in the hospital outpatient or ASC setting for a one-doctor model. Other procedures and imaging may be performed. Society coding recommendations (SIR and ASTRO) vary and are not included in the example scenarios. Contact Sirtex for additional information. PHYSICIAN CODING SCENARIO 1: ONE DOCTOR MODEL (PHYSICIAN ACTS AS BOTH IR AND AU) Medicare 2016 Physician Payment CPT CPT Description Physician (Facility) Physician (Non-Facility) PRE-PLANNING MAPPING CODING Selective Catheterizations for Diagnostic Procedure Selective catheter placement; initial second order abdomen $282 $ ; initial third order or more $334 $1, ; additional second order, third order and beyond $52 $156 Hepatic Angiogram Angiography, visceral, radiological S&I $57 $ Angiography, selective, radiological S&I $18 $88 Embolization (if indicated) Arterial embolization or occlusion, inclusive of all radiological S&I; arterial other than hemorrhage or tumor $517 $7,806 Treatment Planning Treatment Planning; intermediate OR $115 $ Treatment Planning; complex $168 $168 Imaging (coding options will vary based on provider preference) Liver imaging, static OR $21 $ Liver imaging (SPECT) $34 $ Pulmonary perfusion imaging (Medicare NCCI edit 76377) $37 $249 DAY OF TREATMENT CODING Selective catheter placement; initial second order abdomen $282 $ ; initial third order or more $334 $1, ; additional second order, third order and beyond $52 $ Tumor embolization or occlusion, inclusive of all radiological S&I; venous, for tumors, organ ischemia, or infarction $609 $9, Treatment planning should be billed and dictated separately prior to microspheres administration. Page 7 *Status Code J1: Comprehensive APC (C-APC). In 2015 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) or (J!) (with the exception of Yttrium-90 brachytherapy sources billed under C2616). Rights Reserved. 281-U
8 Medicare 2016 Physician Payment CPT CPT Description Physician (Facility) Physician (Non-Facility) Basic Dosimetry Calculation $33 $ Radiopharmaceutical therapy, by intra-arterial particulate admin $117 $117 Post Treatment Imaging (coding options will vary based on provider preference) Liver imaging, static $21 $ Liver imaging (SPECT) $34 $ CTA; with and without contrast $72 $ CTA; abdomen & pelvis, with & without contrast $92 $92 Page 8 *Status Code J1: Comprehensive APC (C-APC). In 2015 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) or (J!) (with the exception of Yttrium-90 brachytherapy sources billed under C2616). Rights Reserved. 281-U
9 Coding Options for SIR-Spheres microspheres Therapy MEDICARE BASE CASE CODING SCENARIOS PHYSICIAN January 2016 The following coding examples are specific to Medicare base-case coding scenarios typical for one mapping and one treatment in the hospital outpatient or ASC setting for a two-doctor model. Other procedures and imaging may be performed. Society coding recommendations (SIR and ASTRO) vary and are not included in the example scenarios. Contact Sirtex for additional information. PHYSICIAN CODING SCENARIO 2: TWO DOCTOR MODEL (TWO PHYSICIANS, IR AND SEPARATE AU) Medicare 2016 Physician Payment CPT CPT Description Physician (Facility) Physician (Non-Facility) PRE-PLANNING MAPPING CODING IR CODING Selective Catheterizations for Diagnostic Procedure Selective catheter placement; initial second order abdomen $282 $ ; initial third order or more $334 $1, ; additional second order, third order and beyond $52 $156 Hepatic Angiogram Angiography, visceral, radiological S&I $57 $ Angiography, selective, radiological S&I $18 $88 Embolization (if indicated) Arterial embolization or occlusion, inclusive of all radiological S&I; other than hemorrhage or tumor $517 $7,806 Imaging (coding options will vary based on provider preference) Liver imaging, static OR $21 $ Liver imaging (SPECT) $34 $ Pulmonary perfusion imaging (Medicare NCCI edit 76377) $37 $249 AU CODING Treatment Planning; intermediate OR $115 $ Treatment Planning; complex $168 $168 DAY OF TREATMENT CODING AU CODING Basic Dosimetry Calculation $33 $ Radiopharmaceutical therapy, by intra-arterial particulate admin $117 $117 IR CODING Selective catheter placement; initial second order abdomen $282 $ ; initial third order or more $334 $1, ; additional second order, third order and beyond $52 $ Tumor embolization or occlusion, inclusive of all radiological S&I; venous, for tumors, organ ischemia, or infarction $609 $9,912 Post Treatment Imaging (coding options will vary based on provider preference) Liver imaging, static $21 $ Liver imaging (SPECT) $34 $ CTA; with and without contrast $72 $ CTA; abdomen & pelvis, with & without contrast $92 $92 14 Treatment planning should be billed and dictated separately prior to microspheres administration, Page 9 Rights Reserved U-0416.
10 Coding Options for SIR-Spheres microspheres Therapy 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-10-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 non-stranded ) mapped to Revenue Code 0278 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: 0 It is important to consult with the hospital finance department to determine the appropriate charges for the microspheres. Page 10 Rights Reserved U-0416.
11 Page 11 Rights Reserved. 281-U-0416
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