Coding Corner March 2010

Coding for Collagenase Injections in the Treatment of Dupuytren’s Disease

By Dan Nagle, MD
Practice Division Director

Auxilium, Xiaflex and Pfizer

The Auxilium Xiaflex marketing tsunami is washing over the United States as well as Europe and Eurasia.  While Auxilium will handle the marketing and regulatory issues in the United States, Pfizer will take on these tasks in 27 countries in Europe and in an additional 19 countries in Eurasia.  Xiaflex is still owned by Auxilium.

Request for a New CPT Code

The advent of this new technology has spurred interest in the creation of a new CPT code. The deadline for submission of a CPT proposal for a new code for CPT 2011 has passed.  The first opportunity to move ahead for CPT 2012 requires submission of a proposal before November 2010. Currently however, there is insufficient peer-reviewed literature to support a request for a Category I CPT code.  The new CPT literature criteria, require five references of which at least three report the procedure/service in a US patient population – of these, at least two articles must report different patient populations or have different authors (i.e., no overlapping patient populations or no overlapping authors).

Drug Reimbursement

Auxilium has suggested Medicare will reimburse the provider for the cost of the drug plus 6%.  The provider is required to purchase the drug and then submit a request for payment to CMS listing HCPCS codes J3590 (Unclassified biologics) or J3490 (Unclassified drugs). I am unaware of any CMS reimbursement to date.

Auxilium has contracted with various pharmacies to handle the delivery of the collagenase for non-Medicare patients. It is my understanding these pharmacies will handle the insurance preauthorization process as well as the delivery of the drug.

The current purchase price for one dose of collagenase from Auxilium is $3,200.

Coding

ASSH coding committee members have discussed coding options with Auxilium. Auxilium has also engaged outside consultants to develop coding recommendations.

Table 1 provides coding suggestions for four patient encounters: evaluation, injection, manipulation and follow-up. Evaluation and Management coding should follow the E&M guidelines contained in the CPT manual.

Table 1. Coding suggestions
 

Four illustrative coding scenarios are listed in table 2 below. The first two (1a and 1b) assume the physician sees a new or established patient and uses level 2 E&M coding.  The second two scenarios (2a and 2b) assume the physician sees a new or established patient and applies level 3 E&M codes. These coding recommendations should not be considered exhaustive, as other coding combinations are possible. Table 3 lists the Medicare data for each code.

Table 2. Illustrative coding scenarios

Table 3. Medicare fee schedule data. (Glob = Global Period, RVW = Physician Work RVU.)

Table 4 lists the economic impact per hour of providing the service described in each scenario. The cost of each scenario was calculated using the CMS approved hourly hand surgery practice expense and the current Medicare reimbursement for physician work  (RVW), practice expense and professional liability insurance (PLI).

Table 4. Economic impact of each scenario
 

Please note these calculations did not include 29130 (Application of finger splint; static) as it was felt therapists would frequently provide this service. Also please remember these calculations are for Medicare reimbursement only.  The economic impact on your practice for providing this service will be a function of your non-Medicare contracts and your Medicare patient volume.

Other Coding Options

The collagenase injection could be coded with 26989 Unlisted procedure, hands or fingers.  This of course would require submission of supporting material including a rationale for the fee requested and a description of the procedure and care provided. 

Code well!

Dan

PS: I have no conflict of interest in regard to Auxilium or Pfizer.

Please note: CPT codes and descriptors are Copyright AMA. Ultimately, coding decisions are the responsibility of the physician.

Revised 3/29/10