Billing for Donor Lymphocyte Infusion related services
I am seeking guidance specifically on the compliant billing of Donor Lymphocyte Infusion (DLI) services post Allogeneic Stem Cell transplant. Often a DLI is needed post transplant and the Donor of the stem cell of the allo stem cell tranplant is brought back in to collect the additional lymphocytes needed.
I understand that all Donor related services for the actual STem Cell transplant should be held and reported as Donor Acquisition charges under 0815 Rev Code when the transplant occurs. HOwever, DLI may not take place for months following a transplant. I have reveiwed the Be the Match site and cannot find the answers I am seeking.
Should the Donor Lymphocyte collection and cell processing charges be reported on the same claim for the recipient's DLI infusion when it takes place?
If it should be reported do you use the 0815 rev code or a separate Lab related rev code since a DLI is not technically a stem cell transplant?
Should Donor services for the DLI not be billed to a payer at all but captured internally and adjusted to the cost report?
Thanks for any assistance.
Comments
Checking in to see if anyone has insight on this, as we have a similar question.
@cstarnes we do know that code 0815 is not used.
We have the same question here: Should the Donor Lymphocyte collection and cell processing charges be reported on the same claim for the recipient's DLI infusion when it takes place?
Is there a diagnosis code or something that alerts the payor that the claim is for donor services?
Thanks!
Beware: the answer below is long b/c the issues are complex because there are no perfect options for billing because there is no specific CPT code for the collection of lymphocytes and neither AMA/CPT or CMS has provided guidance on how to bill for the collection of lymphocytes from a donor for a recipient’s DLI procedure.
Providers have several options each with some layers and additional workflow questions, that I can't get into deep here, but I'll do my best to summarize based on my team's deep thinking about this and based on our discussions with providers. At the end of the day however, each facility will need to select what works best based on its internal processes and policies.
Let’s start with what we know. The DLI procedure is provided post-transplant (to the patient that got the transplant) and is reported with CPT code 38242. That is easy.
The lymphocyte collection procedure, however, performed on the donor in order to get cells for the recipient does not have a specific code nor can CPT code 38205 be used (a question that comes up a lot) since that is specific to collection of hematopoietic stem cells (HSCs) for the purpose of transplant and this isn’t a transplant.
So one option of course, per AMA/CPT coding guidance, is that when a specific CPT code does not exist, it is appropriate to report an unlisted code. In this case, CPT code 38999 can be used for collection and processing of lymphocytes. Revenue code 0815 would not be correct, since this is for lymphocyte collection (and not HSCs for stem cell transplant), but revenue code 0940 (other therapeutic services) or revenue code 0761 (treatment room) are good options.
With this option, we often hear concerns about commercial payer issues coming up, so check payer policies on whether unlisted codes are accepted, prior auth requirements, and how the contract is set up with respect to billing and payment.
Medicare however does provide separate OPPS/APC payment for CPT code 38999 (about $400 based on the APC assignment) but this option may raise questions about when the bill gets sent, ensuring how the donor does not accidentally get billed, the recipient being confused for getting a bill for a service they did not receive (proactive financial counseling can help address this) etc.
Reporting ICD-10-CM diagnosis code Z52.008 for unspecified donor, other blood in the remarks field could help the payer better understand that while the diagnosis specifies donor in the description, the recipient is the guarantor for the cells needed for the DLI procedure. The dx coding index helps since it indicates that Z52.008 is for the collection of lymphocytes, not elsewhere classified.
The other main billing option we see, if providers are willing to forgo the $400 or so in Medicare OPPS/APC reimbursement, is to create a single charge for the DLI procedure inclusive of lymphocyte cell collection and cell processing cost. The rationale is that you have to have the cells in order to provide the DLI procedure to the recipient.
My bias is to line item detail out things for services rendered with CPT codes and have charges drop real-time, but this situation raises enough questions for me that the single DLI charge option is looking good. This is mostly because we do not have a specific CPT code for the lymphocyte collection, no instructions from CMS about how to handle the reporting of this collection from donors (do not confuse this with the clear instructions from CMS about from moving charges for donor search and cell acquisition for an allo stem cell transplant to the recipient’s transplant claim), commercial payer complexities, a donor accidentally getting billed, etc.
As long as this second option is developed properly and providers recognize they are giving up Medicare reimbursement (albeit, it's not huge and the # of DLIs is small) it may be worth it given the time and resources needed to implement workarounds to the issues raised.