The New Apheresis and Blood and Marrow Transplantation–Related Current Procedural Terminology Codes for Payment of Apheresis and Blood and Marrow Transplantation Services

Article Outline

• Abstract
• Introduction
• Apheresis codes: 36511-36516
• Unrelated donor search and hematopoietic progenitor cell acquisition: 38204
• Allogeneic and autologous peripheral hematopoietic cell collection by apheresis: 38205-38206
• Cell-processing codes: 38207-38215
  • 38207: Cryopreservation and Storage—Bone Marrow Peripheral Blood Progenitor Cells
  • 38208 (Transplantation Preparation for Hematopoietic Progenitor Cells, Thawing of a Previously Cryopreserved Progenitor Cell Harvest without Wash) and 38209 (Transplantation Preparations for Hematopoietic Progenitor Cells, Thawing of a Previously Cryopreserved Progenitor Cell Harvest with Wash)
  • 38210: Specific Cell Depletion within a Harvest—T-Cell Depletion
  • 38211: Specific Cell Depletion within a Harvest—Tumor Purging
  • 38212: Specific Cell Depletion within a Harvest—Red Cell Removal
  • 38213: Specific Cell Depletion within a Harvest—Platelet Depletion
  • 38214: Plasma Volume Depletion
  • 38215: Cell Concentration of Plasma Mononuclear Buffy Coat Layer
• CMS concerns with cell processing
• Donor lymphocyte infusions: 38242
• Nongovernmental payers
• Critical care codes: 99291-99292
• Summary
• Acknowledgments
• Bibliography
• Copyright

Abstract 

To address deficiencies in Current Procedural Terminology (CPT) codes that describe many of the clinical services offered to patients, several physicians in the blood and marrow transplantation and apheresis field joined with a coalition including the American Society of Hematology, American Society for Blood and Marrow Transplantation, American Association of Blood Banks, American Society of Clinical Oncology, American Society for Apheresis, National Marrow Donor Program, and American Red Cross to collaborate in addressing these deficiencies by designing new CPT codes. The CPT editorial panel approved 18 new or revised codes. All these codes were given permanent or temporary value by the relative value unit update committee, but not all values were approved by the Centers for Medicare & Medicaid Services (CMS), in particular, the cell-processing codes and the unrelated donor search code. Further discussions addressing these concerns are under way with the CMS. Use of these new codes allows apheresis and transplant centers to charge appropriately for these services. This will help transplant center contracts with CPT codes, with payers more specifically describing services offered to these patients. In turn, this will give better justification for payment. This may allow certain payments for services to increase and help transplant centers better allocate revenue from fixed global case rate payments. Details about the individual codes and their approval process are reviewed in this article.

Key words:  Current Procedural Terminology , Apheresis , BMT , Payment

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Introduction 

For many years, hospitals and physicians providing blood and marrow transplantation (BMT) and apheresis services were frustrated and disadvantaged by the lack of adequate procedure codes to describe and bill for components of BMT services. For example, there was only 1 cell-processing code, 86915, whose descriptor was the removal of T and B cells. The American Medical Association (AMA) Current Procedural Terminology (CPT) staff recommended that all cell processing, including freezing and thawing stem cells and removing red blood cells and plasma, be billed under code 86915. This recommendation was inadequate because the techniques required for any of these different steps consume significantly different resources. The Centers for Medicare & Medicaid Services (CMS) commonly applies a “2 times” rule when defining homogenous groups of procedures for payment purposes; therefore, any individual step (eg, freezing of stem cells versus removal of red cells) that has a resource consumption of greater than 2 times its counterpart should never be placed in the same payment group. To achieve appropriate payment, CPT codes require specificity, which is often referred to in the coding system as granularity. The apheresis and BMT issues met these criteria.

In 1992, the Healthcare Financing Administration, the predecessor to the CMS, implemented the Resource-Based Relative Value Scale (RBRVS) for payment of physician professional services. The originating RBRVS regulation mandated 1 payment per CPT code per patient bill. Payments made under the RBRVS system were arranged into 3 components. All CPT codes were valued for (1) physician services, (2) malpractice expense, and, if applicable, (3) practice expense. Practice expense should pay for the technical services provided for the procedure, including technician work effort, supplies, building and equipment costs, and overhead. In 1999, the Health Insurance Portability and Accountability Act mandated that all payments for interstate medical services be billed by using common code sets according to the Healthcare Common Procedure Coding Systems (HCPCS). Level I codes were defined as the CPT codes. HCPCS level II codes are generally used for services that help to facilitate purchasing outside products, such as blood products or pharmaceuticals, and administering them to patients. These 2 events furthered concerns of the BMT community about the lack of CPT codes to fully describe the services, including the variation in resource consumption.

To address these deficiencies, in 2001, several physicians in the BMT and apheresis field and the American Society of Hematology (ASH) worked collaboratively to design new CPT codes for BMT and apheresis services. A coalition was formed to assist in this endeavor, including the ASH, American Society for Blood and Marrow Transplantation, American Association of Blood Banks, American Society of Clinical Oncology, American Society for Apheresis, National Marrow Donor Program, and American Red Cross. Consultation was also performed with relevant international societies, particularly the International Society of Cellular Therapeutics. The objective of the initiative was to obtain new CPT codes to meet the needs of the hematopoietic progenitor cell and apheresis community. These new codes would be used to obtain adequate payment by describing and documenting the clinical service associated with BMT and apheresis. Because cross-subsidization is being discouraged by the CMS and other third-party payers, additional tangential benefits of the initiative included facilitating appropriate cost-finding techniques for these services and using the values associated with these codes for equitably allocating internal distribution of fixed case-rate payments for global BMT services. This article describes the actions taken to develop new codes and their current status. Some background, however, would first be useful.

Proposals for new CPT codes for medical procedures not adequately defined by current CPT codes are sent to the AMA CPT editorial panel, where they are considered and voted on (Figure 1). For Medicare purposes, newly approved CPT codes are sent to the AMA/Specialty Society Relative Value Scale Update Committee (RUC). This committee evaluates the physician work effort for the procedure in relation to all other services on the physician fee schedule and assigns the procedure a relative value unit (RVU; Figure 2). The committee also evaluates the direct practice expenses (eg, technical staff, supplies, and equipment) incurred by physicians in performing a service in the outpatient setting. The RUC sends its recommendations on both physician work and practice expenses to the CMS, which may accept, not accept, partially accept, or reject the recommendations. As discussed below, for some of the new transplant-related codes, the RUC’s recommendations were not accepted by CMS. (Note: The costs incurred by the hospital for outpatient care are reimbursed through different payment systems; however, these payments are still based on the CPT code system.)

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• Figure 1. 

  The CPT process.

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• Figure 2. 

  The RUC process. RVS indicates Relative Value Scale.

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Apheresis codes: 36511-36516 

Historically, apheresis included only generic apheresis codes: a plasma pheresis code and a photopheresis code. New codes were needed to appropriately bill expenses for differing apheresis services because of the variable cost of disposables and the higher intensity of involvement of the personnel overseeing and performing these procedures, particularly those performed on an emergency basis, such as plasma exchange for thrombotic thrombocytopenia purpura or leukapheresis for newly diagnosed myeloid leukemias with very high leukocyte counts. This is important because the time for performing a white blood cell removal or plasma exchange may be far greater than that for a platelet exchange or for a red blood cell removal. To achieve this specificity, or granularity, therapeutic apheresis has now been split into 36511 for leukapheresis, 36512 for red blood cell exchange, 36513 for platelet pheresis, 36514 for plasma pheresis, 36515 for plasma pheresis with extracorporeal immunoabsorption and plasma reinfusion, and 36516 for plasma pheresis with extracorporeal selected filtration and plasma reinfusion. The code for photopheresis was left unchanged. The Practice Expense Advisory Committee valued several of the new codes as non–facility-based services (36514, 36515, and 36516). Each code is priced for disposables and nursing care (see Table 1 for the payment schedule). In 2004, the RUC committee clarified that the procedure’s professional fee does not require the physician to perform the procedure, but it does require the physician to examine the patient during the procedure, demonstrate active supervision of the procedure, and be available during the procedure. The physician should document the examination and active supervision. Available means that the physician must be in the hospital or facility, but not necessarily in the apheresis suite, during the entire procedure. Physicians do not need to bill a professional fee for these services and should not if they are not on the premises and do not document any supervision of the procedure. A facility fee can be billed. Evaluation for apheresis is billable separately as long as it is performed on a different day and can be done as a consult evaluation and management (E/M) code. The postprocedure follow-up is also billable separately as long as it is performed on a different day by using standard E/M services. Different physicians from the same specialty may bill for inpatient services on the same day. For example, 1 hematologist may follow up acute leukemia patients on the inpatient unit while a second hematologist performs the apheresis.

Table 1. Comparison of Old Pheresis Codes with New Codes

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Unrelated donor search and hematopoietic progenitor cell acquisition: 38204 

The 38204 code covers the medical judgment/decision making of the physician supervision of coordinators performing the unrelated donor search and the cognitive work effort involved in evaluating and selecting the clinically appropriate product (Table 2). The physician assessing a patient for a BMT is often not the physician supervising the donor search, because the donor search requires a detailed knowledge of HLA antigens. Historically, the clinical services required for procuring clinically appropriate unrelated donor cells were billed either with no CPT code or with a generic CPT code, such as 38999 (unlisted procedure, hemic or lymphatic system). This code cannot be used for services purchased through the National Marrow Donor Program or cord blood banks, such as DR testing or requesting a simple confirmatory typing (see Table 2 for payment schedule). For the facility component, this code will be listed as facility based. Although this code was originally developed to cover the physician’s work effort in supervising the search process, it could also conceivably be used for billing the administrative costs associated with an unrelated donor or cord blood search. This code may be used only once per search whether successful or unsuccessful, no matter how long the search lasted. Essentially, the valuation reflects an average amount of time and effort spent by a physician in managing a donor search. If a second transplantation is required from the same donor, this code may not be used twice; however, if a second transplantation is performed from a different donor, whether marrow, peripheral blood stem cells, or umbilical cord blood, this code may be used a second time. To bill this code, the physician must document the cognitive work effort of reviewing the donor search and donor selection, as well as the negotiations with the appropriate collection center for the service. CMS rejected the RUC’s recommendation and questioned the degree to which physicians are typically involved in these services. CMS believes that the donor search is already a covered benefit under the allogeneic infusion CPT code (38240) for physician work effort. This code was an original CPT code; however, CPT never fully defined the scope of work, and RUC has not resurveyed the work effort. Most centers have limited the scope of work to management of the allogeneic progenitor cell infusion. The physician managing the donor search is rarely the physician performing the infusion, because the inpatient physician usually performs the infusion. ASH has had several discussions with CMS about this issue and continues to seek to have this decision reversed.

Table 2. Donor Search

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Allogeneic and autologous peripheral hematopoietic cell collection by apheresis: 38205-38206 

The original common code for peripheral stem cell collection (38231) was revised and split into 2 codes. This code was originally published in CPT in 1999 as a solitary code for apheresis stem cell collection. The code’s definition did not specify allogeneic or autologous transplantation (Table 3). Additionally, code 38231 did not effectively clarify whether charges were global or per diem, and this created confusion on how to bill stem cell collection services requiring multiple days of collection. There are 2 new codes for stem cell collection—38205 for allogeneic and 38206 for autologous peripheral blood progenitor (stem) cell collection. The codes are to be reported only once per day. The physician billing for supervision for these codes may not bill E/M services on that day. However, the precollection assessment can be billed under a standard E/M as long as it is not performed on the same day the service is provided. Similarly, the postpheresis follow-up can also be billed under standard E/M as long as it occurs on a different day than that of the procedure. As with the apheresis CPT codes, to bill for a professional fee, the physician does not have to perform the procedure but must examine the patient during the procedure and demonstrate active supervision of the procedure. The physician should document this activity. The physician must remain in the hospital for the entire procedure and be readily available if needed at the bedside. The physician does not need to be in the apheresis suite for the entire procedure. There is a per-day physician charge for both of these codes when multiple collections are required, and this charge may be billed on multiple days. Please note that the assessment of an allogeneic donor should be billed as a new patient charge and not as a consult because there is no referring physician for a donor visit. The autologous pre–stem cell collection may be billed as a consult history and physical if the physician performing the apheresis is different from the physician managing the patient’s cancer, if other requirements for consultation are met. This can be within the same specialty; however, the consult cannot be performed on the day of collection. CPT codes 38205 and 38206 are valued and approved by CMS. Unlike the apheresis codes, these codes are only facility-based codes. This means that the use of these codes is limited to hospitals or hospital-based facilities. Before these services are assessed for non–facility-based centers, the effect of the new Food and Drug Administration (FDA) policies and proceedings under Code of Federal Regulations (CFR) 1271 must be evaluated. Facility-related expenses may include valuing services such as technician time, machine disposables, machine depreciation, space utilization, and all costs associated with meeting regulatory components, which is of importance to exempt cancer centers. Hospitals are reimbursed on the ambulatory patient classification system based on Medicare claims data. The ambulatory patient classification system bundles hospital payments for nursing, technician time, supplies, equipment, and hospital overhead.

Table 3. Comparison of Old Stem Cell Collection Codes with New Codes

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Cell-processing codes: 38207-38215 

The new cell-processing CPT codes (38207 through 38215) were written to allow granularity for cell processing because the old code, 86915, could not be priced uniformly to compensate for all cell-processing procedures. In 1999, when CMS approved the new CPT codes for stem cell collection (38231), it also approved a reference to 2 new codes, 88240 and 88241, which are for freezing and thawing of aliquots of cells. These codes were written by the American Genetics Society for the purpose of transferring cells for cytogenetic testing in different laboratories (Table 4). They were never intended to be valued on the facility side for the processing of a transplantable therapeutic product. During the writing of the new CPT codes for cell processing, consideration had to be given to the fact that the CPT editorial panel would give new codes only for procedural processes that are generally accepted as a standard of care. Codes for stem cell expansion and vaccine preparation were not proposed because these technologies are still in the developmental stages and not FDA approved. Cell-processing procedure definitions were based on the purpose of the cell processing rather than a link to any one manufacturer’s device. The CPT editorial panel and the RUC committee agreed that these codes would be per-day charges. These codes were defined and valued with the perspective that the quality-assurance testing was part of the code.

Table 4. Comparison of Old Cell Processing Codes with New Codes

The RUC committee established temporary RVUs for all of these codes. The RUC agreed that the physician RVUs were developed for review of data important for all cell-processing decisions; supervision of the technician performing an individual patient’s cell processing; review and interpretation of quality-assurance procedures for individual patient cells being processed, including flow cytometry; and preparation of a report on an individual product’s adequacy and the ability of that cellular product to meet expectations for transplantation. However, it should be emphasized that this physician work effort does not include quality assurance for the entire laboratory and that quality assurance is not being performed for an individual patient but for the laboratory processes and procedures. Included in the physician work effort is a product specific report that documents the adequacy of the product to meet the goals of the transplantation.

38207: Cryopreservation and Storage—Bone Marrow Peripheral Blood Progenitor Cells 

The code 38207 is for the freezing and storing of hematopoietic and lymphopoietic cells for transplantation. Physician judgment and review issues for this code include donor/recipient HLA typing; mismatching; ABO compatibility; infectious disease serology; donor/recipient size disparity; red blood cell contamination of the product collected; appropriate quality-assurance procedures such as CD34, CD3, and microbiology testing; technician review of the freezer curves; and report generation to review the adequacy of the cryopreserved product and its ability to meet specifications for the intended transplantation. Facility fees include technician time, laboratory supplies, machine depreciation, and space utilization. Mononuclear cell processing should be billed separately if it is performed before cryopreservation. Cryopreservation facility charges include all quality-assurance testing for that individual product. Since January 1, 2004, all flow cytometry procedures for quality assurance of an individual product are included in this code.

38208 (Transplantation Preparation for Hematopoietic Progenitor Cells, Thawing of a Previously Cryopreserved Progenitor Cell Harvest without Wash) and 38209 (Transplantation Preparations for Hematopoietic Progenitor Cells, Thawing of a Previously Cryopreserved Progenitor Cell Harvest with Wash) 

A separate code for thawing, as opposed to cryopreservation, was necessary because not all cryopreserved products are actually thawed. This code is intended for the thawing of the harvest from the day of infusion. This code is a per-day code like the other cell-processing codes. The physician work effort here is a review of special procedures necessary for the thawing of the product, including needs for washing the product or addressing concerns about incompatible red blood cell contamination. The facility component includes all equipment, machine depreciation, space utilization, technician time used in the thawing process, and postthaw viability testing. If there is any postthaw flow cytometry testing, then it should be included as a part of the facility and professional component. Starting in 2004, 38208 is for a thaw without a wash and 38209 is for transplantation preparation of hematopoietic progenitor cells and thawing and washing a previously cryopreserved product. Code 38209 was designed for washing thawed cells to remove dimethyl sulfoxide. The facility fees should include technician time, machinery, supplies, machinery depreciation, and prewash and postwash viability testing.

38210: Specific Cell Depletion within a Harvest—T-Cell Depletion 

The code 38210 covers the removal of T cells from a bone marrow or stem cell harvest to prevent graft-versus-host disease. The physician work assessment and decision making is assessing the need for T-cell depletion for prevention of graft-versus-host disease; assessing donor/recipient suitability for a T cell–depleted transplant, including HLA typing and donor/recipient size disparity; assessing the quality of the product coming to the laboratory for T-cell depletion; obtaining CD34 and CD3 counts; supervising the technician processing the hematopoietic progenitor cells for T-cell depletion; assessing the efficacy of the T-cell depletion; and judging the quality of product adequacy. Facility fees include the machinery, machinery depreciation, technician time, space utilization, and quality-assurance testing.

If cryopreservation (38207) is to be performed before infusion, then cryopreservation should be charged separately. If mononuclear cell separation (38215) is not usually performed before T-cell depletion, then it may also be charged separately. The facility fee should include the test to evaluate the efficacy of T-cell depletion and the product viability after T-cell depletion, and these will include preprocessing and postprocessing.

38211: Specific Cell Depletion within a Harvest—Tumor Purging 

Tumor purging is similar to T-cell depletion and is used for an autologous product to purge contaminating tumor cells. Physician decision making and assessment consists of determining the necessity for tumor purging, assessing the quality of the product received in the laboratory for tumor purging, supervising technical staff, assessing the efficacy of the procedure, and reviewing the quality of the product to meet specifications. The facility fees should include all the machinery equipment, depreciation, technician time, space utilization, and supplies for performing tumor purging. Because cryopreservation is always performed in the context of tumor purging for an autologous transplantation, this should be included in the charge. Mononuclear cell separation is not always performed before tumor purging and should not be included in the pricing.

38212: Specific Cell Depletion within a Harvest—Red Cell Removal 

This CPT code should be used for a fresh allogeneic bone marrow harvest with major ABO incompatibility for removal of red blood cells in preparation for transplantation. Facility fees include technician time, supplies, machinery, and red cell blood depletion for a major ABO-incompatible marrow harvest. This is performed for quality-assurance testing for the efficacy of red blood cell removal, as well as for the viability of progenitor cells after red blood cell removal. Starting in 2004, this CPT code includes flow cytometry testing for quality assurance.

38213: Specific Cell Depletion within a Harvest—Platelet Depletion 

Code 38213 is for a donor undergoing a multiple-day progenitor cell harvest who requires a platelet soft spin to add back platelets as a result of a decrease in platelet count after the progenitor cell collection. There has been controversy about whether there are any RVUs because there is no explicit quality assurance of this product after it is given back to a donor with a low platelet count.

38214: Plasma Volume Depletion 

Plasma volume depletion is performed on a fresh bone marrow harvest for plasma removal for the purposes of either minor ABO incompatibility or volume reduction in the circumstance in which the donor is much larger than the recipient.

38215: Cell Concentration of Plasma Mononuclear Buffy Coat Layer 

Cell concentration of the plasma mononuclear buffy coat layer is for mononuclear cell separation for either major or minor ABO incompatibility from a fresh bone marrow harvest or when a mononuclear cell separation is necessary for further cell processing, such as T-cell depletion or tumor purging. This should be billed in the latter circumstance only if is not routinely performed for all purging or procedures. The professional work component includes assessing the need for mononuclear cell separation; reviewing the donor/recipient size, ABO blood types, and the quality of the product reaching the laboratory; ensuring that the product after processing meets the patient’s specific needs; and generating a report. Facility fees include technician time, supplies, machinery, and viability testing, including flow cytometry.

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CMS concerns with cell processing 

CMS did not approve the cell-processing codes 38207 to 38215. CMS chose not to value these services but chose to create HCPCS level II codes in the G-code section for cell processing (G0265, G0266, and G267). The G-codes G0265 and G0266 mirror codes 88240 and 88241 and have been valued by CMS for cell processing at approximately $11 for facility compensation only. There is no professional fee compensation for any HCPCS level II G-codes. CMS attached these codes to the laboratory fee schedule as a result of its belief that cell processing is entirely automated. CMS seems not to appreciate the unique nature of BMT services and why these are different from simply sending cells across state lines for routine laboratory testing. How the FDA’s new policies and procedures with CFR 1271 will affect CMS’s thinking is unknown. Further discussions with CMS are under way. Preparation of a patient-specific cellular product for transplantation is a novel concept to CMS, especially in light of 8 codes replacing 1 code. The BMT community had never participated in this process, which is why so many new codes were needed. However, codes 38207 to 38215 can and should be used for billing these services to nongovernmental payers. These new codes will more accurately describe BMT services to nongovernmental payers. With CMS’s lack of coverage, the BMT community is not worse off than it historically was when codes 88240 and 88241 were valued as facility expenses by CMS at $11 and also did not have professional fee compensation. Code 86915 was valued at only $32. G-code G0267 would be used for CPT code 86915 for a facility charge for procedures other new cryopreservation and thawing. These codes were presented as facility-based for practice expense allocation. CMS has no historical data for these codes. Cell-processing expenses, if reviewed at all, fell under the inpatient diagnosis-related groups for nonexempt cancer centers or outpatient donor bills. BMT is an infrequent procedure for Medicare beneficiaries because, until recently, BMT was limited to patients younger than 45 years of age. This has impeded CMS from collecting accurate data about BMT services.

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Donor lymphocyte infusions: 38242 

Billing donor lymphocyte infusions to treat relapse or viral infections after an allogeneic transplantation is problematic. Many institutions used the allogeneic transplantation CPT code 38240, but this code was difficult to justify with the small volume of cells used to treat viral infections. For this reason, several members of the specialty coalition working on these codes insisted on creating a new code to clearly define this service (Table 5). An additional reason for this code was that different physicians often performed the initial transplant infusion and the donor lymphocyte infusion. The code was clearly defined as a single-day service limited to managing complications with the donor lymphocyte infusion and the risk associated with the infusion. The physician work effort includes reviewing the donor-recipient identity, approving the cell dose infused to meet the clinical needs of treating the recurrent malignancy or infection, obtaining consent from the patient, ordering the premedications, infusing the product, and managing any acute toxicities with the infusion. The professional liability risk includes all of the former, plus the risk of long-term complications. If the cell-processing laboratory performs the cryropreservation and thawing of the product for the infusion, then the cell-processing facility services, including patient-specific quality assurance, should be charged under those codes. In the outpatient setting, the facility services would include nursing care management. If neither cell processing nor cryopreservation is necessary, then the facility fee may also include the quality-assurance testing of the product. This also applies to CPT code 38240 for fresh infusions when no cell processing is performed.

Table 5. Comparison of Old Cell Infusion Codes with New Codes

N/A indicates not applicable.

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Nongovernmental payers 

For the nongovernmental payer, there is a need to set rates for these services in the provider’s charge description master file. In the case of all new CPT codes, decisions about rate setting must be made without the benefit of market data. It is easier to defend rates for these services if the rates for these services are developed from a cost of service. One accounting method for achieving appropriate rates based on cost is the activity-based costing (ABC) method. The focus of this costing approach is defining the “activities as the fundamental cost objects” and using “the costs of these activities as building blocks for compiling the costs of other cost objects.” That is, costs are accumulated for each step in the cell-processing process and are then collected and applied to specific new CPT codes separately, as applicable. With this approach, the cell-processing procedures can be reviewed step by step. The activities can be documented, and the cost of each activity along the continuum of processing the cells is recorded in a building-block fashion. Once all activities surrounding a procedure are defined and documented, other cost drivers—such as overhead, equipment, and building expenses—can be further stacked to produce a fully loaded cost per procedure. Although this process can be time consuming, it provides excellent justification for rates when there is no established market rate. The role of an administrative professional is to challenge the clinician to consider all the costs involved in each step and to map those steps to the applicable individual CPT code. The role of the clinician is to impart the clinical expertise about the process so that all costs can be identified and valued. Costs in the case of stem-cell processing range from technician time to liquid nitrogen to quality-control measures, with much more in between. The results of the ABC method can provide robust information for rate setting, managed care contract negotiation, and properly supporting and defending payments with government regulators and payers. The ABC method is a bottom-up approach to determining practice expense, as opposed to the top-down methodology used by CMS. At M.D. Anderson Cancer Center, the decision was made to price the services these codes describe in relation to the cost of performing the service. This would be the most defensible approach to payers and potentially would help in the equity of internally allocating global fixed payment case rates. Better accounting for these services through the use of these CPT codes will help BMT providers and payers to negotiate fairer case-rate payment prices. Time/motion studies were used to assess technician time, supplies, machine use, machine depreciation, space costs, facility malpractice risk, quality assurance, testing on an individual product, and institutional overhead to develop a cost-based pricing. The pricing may actually include an amortization of good manufacturing practice laboratory construction costs; however, the amortization must be over 10 years.

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Critical care codes: 99291-99292 

Although the critical care codes are not new, given the serious condition of inpatient BMT patients, strong consideration should be given to using critical care codes to describe inpatient physician services rather than standard inpatient E/M codes (99221-99233). The criteria for critical care service and critical care can be rendered for patients not in the medical intensive care unit. Critical care is defined as direct delivery of care by a physician for a critically ill or critically injured patient when there is a high probability for imminent or life-threatening deterioration of 1 or more organ systems. Critical care involves highly complex decision making to assess, manipulate, and support vital system functions to treat single or multiorgan system failure or to prevent further life-threatening deterioration of the patient’s condition. There is an advantage of critical care services because this is a time-based code. Critical care usually pays more than the most complex inpatient E/M codes (Table 6). This code best describes physician services involved in caring for highly unstable BMT inpatients.

Table 6. Comparison of Critical Care Codes with Inpatient Follow-Up Codes

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Summary 

Scientists and clinicians may question why all this administrative distraction is worthwhile. In a technology-driven clinical environment such as BMT, lack of attention to these coding and payment issues could jeopardize the advancement of medical care. Why? Because the coding and payment systems have not kept pace with the clinical technology. Traditionally, BMT providers have been disadvantaged financially by their lack of participation in the payment and rate-setting process. Strenuous efforts are needed to direct the regulatory process forward and to educate regulators on emerging clinical advances. Designing a revenue structure to bill these new codes does require a significant investment of clinician time. Case-rate payment models will not insulate providers from these time requirements. Cost shifting is hard to defend. Cancer care pharmacy charges are being seriously examined under public scrutiny. Pharmacy charges are often 50% of a BMT patient’s total bill. Pressures on payments from government sources and private payers will force clinicians to partner with other professionals to fully describe their services to ensure adequate payments, including global case-rate payments. Trends in health care financing indicate that the BMT community will face heightened scrutiny of clinical laboratory and pharmacy pricing. Traditionally, payments made for those services cross subsidized resource-intense, technologically advanced BMT services such as cell processing, apheresis, and donor searching. Appropriate descriptions of services coupled with appropriate cost-finding techniques will be critical because cost shifting cannot continue to provide adequate compensation for these costs. This is particularly dramatic in the context of the need for BMT providers to build cell-processing laboratories that meet good manufacturing practice standards for the new products and technologies being developed in the field. The new federal regulations for cell processing (CFR 1271) require greater technologist time for product preparation, greater physician supervision, and, for many, facility renovation or construction. Only by specifically billing for cell-processing services will institutions recoup these new costs. Pharmacy and routine laboratory services are under greater security. Finally, with fixed compensation, whether diagnosis-related groups or case rates, the distribution of the case rate within a facility is often dependent on the work effort of the components of the bill. These new CPT codes help clarify these efforts within institutions for better revenue allocation and help reduce risk of fraud and abuse by clear definitions, which were lacking in the old codes.

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Acknowledgments 

The physicians working on this effort are indebted to the staff at the ASH for their assistance.

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