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14 Oncology IssuesSeptember/October 2011
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Coding Bone Marrow Procedures: Something Old, Something Newby Cindy Parman, CPC, CPC-H, RCC
Theinsideofboneisnotsolid,butiscomposedofafinenet-workofmesh-likebonecalled
bonemarrow.Bonemarrowisfoundatthecenterofthebones,especiallytheareasoftheskull,sternum,ribs,backbone,andpelvis.Approximately95percentofbloodcellsareformedinthebonemarrow,andthesecellsarereleasedintothebloodstreamatvariousstagesofdevelopment.Bonemarrowthatactivelyproducesbloodcellsiscalledredmarrow;marrowthatnolongerproducesbloodcellsiscalledyellowmarrow.
Duetotheshortlifespanofmaturebloodcells,whichsurvivefromafewdaystoafewmonths,newbloodcellsarecon-stantlyinproduction.Inhealthyadults,thebodyproducesroughly100billionredcellsand400millionwhitecellseachhour.Todeter-minetheappropriatetreatmentforapatient,itmaybenecessarytoaspirateorbiopsythepatient’sbonemarrowforpathologicanalysis.Thistypeofexaminationcandiagnosebloodorbonemar-rowcancers,detectamalignancythathasspreadtothebonemarrowfromanothersite,checkforinfec-tions,measuretheeffectivenessoftreatment,ordeterminehowwellthebonemarrowcouldfunctionifaggressivechemotherapyweregiven.
Bone Marrow Biopsy and/or AspirationBonemarrowbiopsydescribesthetechniqueofremovingsmallpiecesofcancellousboneviaaneedleortrocar.Generally,thepelviciliumisbiop-siedatthesuperioriliacspine.Othersites,suchasthesternum,thespinousprocesses,orthetibia,maybeused.Abonemarrowbiopsymaybeper-
formedtodiagnosecertaintypesofbloodandbonemarrowmalignan-cies,todetermineifothercancersinvolvethemarrow,oraspartofthestagingprocessformalignantconditions.Theprocedurecodeis:■■ 38221:Bonemarrow;biopsy,
needle,ortrocar.
Abonemarrowaspirationmaybeperformedindependentofabonemarrowbiopsy,ormayimmediatelyprecedeorfollowabiopsy.Abonemarrowaspirationisasufficientpro-cedurewhentherelationshipofthe
infiltratingcellstothebonemarrowisnotrequiredfor
appropriatepatientmanage-ment.Forexample,whenaphysicianisfollowingaknowncaseofleukemia,
thenonlythenatureofthecellularpopula-
tionneedstobeevaluated.Theprocedure
codeforabonemarrowaspirationis:
■■ 38220:Bonemarrow;aspira-tiononly.
Whenbothabonemarrowaspira-tionandbonemarrowbiopsyareperformedthroughthesameincisionduringasingleencounteronaMedi-carepatient,theCentersforMedicare&MedicaidServices(CMS)requiresthephysicianand/orfacilitytoassignaHCPCSLevelIIcodefortheaspi-rationportionoftheservice:■■ +G0364:Bonemarrowaspiration
performedwithbonemarrowbiopsythroughthesameincisiononthesamedateofservice.
Thehealthcareorganizationassignsboththecodeforbonemarrowbiopsy(38221)andtheadd-oncodeG0364forthebonemarrowaspi-ration.BecausecodeG0364isanadd-onHCPCSLevelIIcode,itwillneverbetheonlycodecharged;it
mustbe“added-on”tothecodefortheprimaryprocedureorservice.Inthisscenario,codeG0364replacescode38220fortheaspirationportionoftheprocedure.
Rememberthattheuseofmodi-fier 59(distinctprocedure)oncode38220(bonemarrowaspiration)whenbilledwithcode38221(bonemarrowbiopsy)willbearareoccur-rence.Tobillcodes38220and38221andappendamodifier,thebonemarrowsamplesmustbeobtainedfromdifferentanatomicsites,suchascontralateraliliaccrestsoriliacandsternum,orduringseparatepatientencounters.1Asaresult,whenbonemarrowbiopsyandaspirationarecarriedoutthroughthesameincisionoratthesameanatomicsite,mostnon-Medicarepayerswillreimburseforonlythebiopsycodeand“bun-dle”theaspirationcode(seeTable1).
Harvesting for Transplant Bonemarrowtransplantation(BMT)involvesextractingbonemarrowcontainingnormalstemcellsfromthepatientorahealthydonor,andinfusingitbackintothepatientaftertherapy(autologoustransplant)orintoarecipient(allo-geneictransplant)whosebonemar-rowcannotmanufacturesufficientnormalcells.Thisproceduremaybeconsideredwhenhealthycellshavebeendestroyedduetodiseasepro-cessesorduetotreatments,suchaschemotherapyorradiationtherapy.Thereisauniqueprocedurecodeforthispartoftheprocess:■■ 38230:Bonemarrowharvesting
fortransplantation.
Thebonemarrowisgenerallyhar-vestedundergeneralanesthesia,andobtainedfromtheiliaccrestwithaspecialneedleandsyringe.Thebonemarrowisthenadministeredtothepatientthroughacatheterinsertedintoalargeveinintheupperchest.Fromthebloodstream,thebonemar-
Oncology IssuesSeptember/October 2011 15
guidancerequiredtocompletetheprocedure.Dependingontheindivid-ualcodedefinition,thebonemarrowharvestmayalsobeincludedandnotseparatelycharged.
CategoryIIICPTcodesendingwiththeletter“T”allowdatacollec-tionforemergingtechnology,services,andprocedures,buttheyarenotcon-sistentlyreimbursedbyallinsurers.Thesecodesmayormaynoteventu-allyreceiveastandardCategoryICPTcode.Regardless,aCategoryIIIcodewillbearchivedfiveyearsfromitsdateofpublicationinthecodebookunlessitisdemonstratedthatatempo-rarycodeisstillneeded.
MedicarehasaddedthesenewprocedurecodestothepayablelistfortheHospitalOutpatientProspectivePaymentSystem(HOPPS),effectiveJuly1,2011.However,remembertocontactcommercialandmanagedcarepayerstodeterminetheircoverageguidelinesforthesenewprocedurecodes.
Cindy Parman, CPC, CPC-H, RCC, is a principal at Coding Strategies, Inc. in Powder Springs, Ga.
References1AHACodingClinicforHCPCS.ThirdQuarter;2008.2CobellisG,SilvesetroniA,LilloS,etal.Long-termeffectsofrepeatedautologoustransplantationofbonemarrowcellsinpatientsaffectedbyperipheralarterialdisease.Bone Marrow Transplant. 2008;42:667-672.Availableonlineat: http://www.nature.com/bmt/journal/v42/n10/pdf/bmt2008228a.pdf. LastaccessedJuly1,2011.3Tateishi-YuyamaE,MatsubaraH,MuroharaT,etal.Therapeuticangiogenesisforpatientswithlimbischaemiabyautologoustransplantationofbone-marrowcells:apilotstudyandarandomisedcontrolledtrial.Lancet. 2002;360(9331):427-35.
stratedencouragingresultsbyrevascularizingtheaffectedarea.3
EffectiveJuly1,2011,threenewCPT®CategoryIIIprocedurecodesfortheseservicesareavailable:■■ 0263T:Intramuscularautolo-
gousbonemarrowcelltherapy,withpreparationofharvestedcells,multipleinjections,oneleg,includingultrasoundguidance,ifperformed;completeprocedureinvolvingunilateralorbilateralbonemarrowharvest.
■■ 0264T:Intramuscularautolo-gousbonemarrowcelltherapy,withpreparationofharvestedcells,multipleinjections,oneleg,includingultrasoundguidance,ifperformed;completeprocedureexcludingbonemarrowharvest.
■■ 0265T:Intramuscularautolo-gousbonemarrowcelltherapy,withpreparationofharvestedcells,multipleinjections,oneleg,includingultrasoundguidance,ifperformed;unilateralorbilateralbonemarrowharvestonlyforintramuscularautologousbonemarrowcelltherapy.
Thedefinitionoftheseprocedurecodesincludepreparationofharvestedcells,allinjectionservices,andimage
rowcellswillmigrateintothebonesandbegintoproducenormalbloodcells.Theinfusionortransplantofharvestedbonemarrowisreportedwithoneofthefollowingcodes:■■ 38240:Bonemarroworblood-
derivedperipheralstemcelltrans-plantation;allogeneic.
■■ 38241:Bonemarroworblood-derivedperipheralstemcelltrans-plantation;autologous.
Physicianworkforbonemarrowtransplantincludespatientevaluationbeforetheservice,directsupervisionduringtransplant,andthepost-transplantassessment.
New Codes for Intramuscular TherapyPeripheralarterydisease(PAD)isacommoncirculatoryprobleminwhichnarrowedarteriesreducebloodflow,especiallytothelimbs.Aconditionknownascriticallimbischemiarepresentsthemostdramaticclinicaloutcome.2TheadvancedstagesofPADmayincludegangreneandulceration,whichcouldresultinamputationoftheaffectedlimb.Inpatientsaffectedbyischemiaofthelimb,localintramuscularautologousbonemarrowcelltherapyhasdemon-
Scenario Codes
Table 1. Bone Marrow Biopsy & Aspiration
BoneMarrowBiopsy(soleprocedure) 38221
BoneMarrowAspiration(soleprocedure) 38220
BoneMarrowBiopsy&Aspiration(Medicare) 38221 G0364
BoneMarrowBiopsy&Aspiration(non-Medicare) 38220* 38221
BoneMarrowBiopsy&Aspiration 38220-59Separatenoncontiguousanatomicsites 38221*Thiscodemaybebundledintothebonemarrowbiopsyprocedurecodedependingonindividualinsurancepayerpolicy.