Health Information Management

Q/A: Billing for Provenge

APCs Insider, August 19, 2011

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Q: Our facility’s billing office tells us that our FI/MAC is not reimbursing us for drug administration when we provide Provenge®. We checked our documentation; the dose was given and the nurse documented the start and stop times. We billed the appropriate therapeutic/diagnostic/prophylactic infusion code.

Do you know why this is happening?

A: Provenge (sipuleucel-T) is an autologous cellular immunotherapy treatment. It differs from other infused anti-cancer therapies in that a pharmaceutical company neither manufactures it nor sells it to providers for administration. The patient’s own white blood cells are used to make Provenge. The blood cells are removed by leukopheresis and treated with an antigen and colony-stimulating factor in order to target prostate cancer cells. 

HCPCS code Q2043 (sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, including leukapheresis and all other preparatory procedures, per infusion) is an all-inclusive code. By definition, it includes leukopheresis and “all other preparatory procedures, per infusion.” (Note that HCPCS code Q2043 replaced C9273 effective July 1.)

CMS published two transmittals July 8. Transmittal 2254, CR 7431, updates the Medicare Claims Processing Manual, and Transmittal 133, CR 7431, creates the National Coverage Determination for Provenge.

Transmittal 2254 notes that “all preparatory procedures” refers to the process of collecting the cells during the leukopheresis procedure, sending the cells for processing, transporting them back to the site of service for administration, and infusing the patient. ”The transmittal further states:

Q2043 is all-inclusive and represents all routine costs associated with its administration. Thus contractors will not pay separately for any claims of routine costs associated with Provenge, such as Common Procedure Terminology (CPT) code 96365, intravenous infusion for therapy, prophylaxis of diagnosis (specify substance or drug); initial, up to 1 hour.

CMS recommends reporting Q2043 with revenue code 0636 (drugs requiring detailed coding). Consult your FI/MAC to determine whether its system will process a claim if you report only code Q2043.

Other Integrated Outpatient Code Editor edits may require a token charge with the drug administration code to process it as a complete claim. This is similar to a device code with a token charge to meet device-to-procedure/procedure-to-device edits when a provider receives a device at no cost.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.

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